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MiilMlL

Gift of
Dr. M. "Rineha^rt-

A TREATISE

THE DISEASES

!TEEVOTJS SYSTEM.

WILLIAM A. HAMMOND, M. D.,

BOrSMOB OF DISKAflW OF THS KIND AND NEBVOUS 8T8TE3f IN TDK MEDICAL DEPARnCENT OF
THB r3nTBB8ITT OF THE CITT OF NEWTOBK; PRESISEXT OF THE NEW TOOK MEUBOLOGICAL

■ocarrr; »Einmi of the American PHiLosopnicAL bociett (puiladelfbia), of the

▲CAJIEMT OF THE NATURAL BCIENCE8 (PHILADELPHIA) ; FELLOW OF THE
COLIXSB OF FUmCIAHS OF PHILADELPHIA ; FELLOW OF THE AMERICAN
ACADEMT OF ABTB AND 8CIEN0EB (BOSTON) ; OORREf>PONDIN<» MEM-
BER OF THB ANTHROPOLOGICAL INSTITUTE OF GREAT BIUTAIN
AND IRELAND, ETC., ETC.

WITH ONE HUNDRED AND NINE ILLUSTRATIONS,

fIXTB EDITION, REWRITTEN, ENLARGED AND IMPROVED.

''Est (^aoddam prodirc teniu, b1 dod dator nltro.*'— IIor^ce.

NEW YORK:

D. APPLETON AND COMPANY,

849 k 551 BROADWAY.

187C.
S

EsrmxD, according to Act of Congress, in the year 1S7G,
By D. APPLETON de CO.,

In the Office of the Librarian of Congress, at Washington.

/• ••: .••: : ;

• • • /; • ; ; ?

'*••• •••• •• •••

I dedicate this volume to my dear fidend S. Weir
Mitchell, M.D., of Philadelphia, not only because he
is my friend and fellow-laborer of twenty years'
standing, but because his acquirements as a physician,
and especially a neurologist, are such as to place him
among the first of those who work in the most
important department of medical science.

'5Zb'^

PEEFAOE.

Is the preface to the first edition of this work, published five years
ago, I wrote as follows :

" In the following work I have endeavored to present a Treatise
on Diseases of the Nervous System, which, without being superficial,
woidd be concise and explicit, and which, while making no claim to
being exhaustive, would nevertheless be sufficiently complete for the
instruction and guidance of those who might be disposed to seek infor-
mation from its pages. How far I have been successful will soon be
determined by the judgment of those more competent than myself to
form an unbiased opinion.

" One feature I may, however, with justice claim for this work, and
that is, that it rests to a great extent on my own observation and ex-
perience, and is therefore no mere compilation. The reader will readily
perceive that I have views of my own on every disease considered, and
that I have not hesitated to express them."

In the present edition I am induced to believe that whatever good
features the first and subsequent editions possessed are rendered still
better, and that the faults of the former, if not altogether eradi-
cated, are at least lessened. Certainly I have not failed to take into
consideration the suggestions of my critics, and, when they appeared

Gift of
Dr. A. ■RinehJsrV

CONTENTS,

PJLOl

Introduction, ........ 17

The iDStniments and Apparatus employed in the Diagnosis and Treatment
of Diseases of the Nervous System.

SECTION I.

DISEASES OF THE BRAI2T,

CHAP.

I. — Cebebral Congestion, ...... 83

Active Cerebral Congestion. — Passive Cerebral Congestion.
11. — Cerebral ANJSiaA, . . . . . . .66

IIL — Cerebral H^smorrhage, . . . . . . 66

IV. — Cerebral Meningeal Hemorrhage, .... 108

Pachymeningitis and Hsematoma of the Dura Mater.
V. — Partial Cerebral Anemia from Obliteration op Cerebral

Blood-Ye&sels, . . . . . .116

Thrombosis of Cerebral Arteries. — Embolism of Cerebral Arteries.
— ^Thrombosis of Cerebral Veins and Sinuses. — Embolism and
Thrombosis of the Cerebral Capillaries.
VL— Cerebral Softening, ...... 146

VII.— Aphasia, . . . . * ., .166

VIII. — Acute Cerebral Meningitis, ..... 206

IX. — Chronio Cerebral Meningitis, .... 216

Chronic Verticalar Meningitis. — Chronic Basilar Meningitis.
X. — ^Tubercular Cerebral Meningitis, ... . . 246

XI. — Suppurative Encephalitis or Cerebritis, . . . 263

Cerebria,

10 CONTENTS.

CHAP. ^ PAGE

XII. — Diffused Cebebral Sjdlebosis, ..... 265

XIII.— Multiple Gehebral Sclerosis, ..... 276

XIV.— Tumors of the Brain, ...... 292

XV. — Insanity, ........ 800

General Principles. — Perceptional Insanity. — Intellectual Insan-
ity.— Emotional Insanity. — Volitional Insanity. — Mania. — Gen-
eral Paralysis. — Idiocy and Dementia.

SECTION II.

DISEASES OF TEE SPINAL CORD.

I. — Spinal Congestion, ....... 877

XL — Spinal Anaemia, ....... 886

Anemia of the Posterior Colunms. — Anemia of the Antcro-Latcral
Columns.

III. — Spinal II.£MOBRnAGE — Spinal Meningeal Haemorrhage, . .418

IV. — Spinal Meningitis, ...... 425

Acute Spinal Meningitis. — Chronic Spinal Meningitis.
V. — The Inflammations of the Spinal Cord, . .441

Acute Myelitis. — Infantile Spinal Paralysis. — Spinal Paralysis of
Adults. — ^Pseudo-Hjrpertrophic Spinal Paralysis. — Glosso-Labio-
Laryngeal Paralysis. — Progressive Muscular Atrophy. — Pro^
gressive Facial Atrophy. — Tetanus. — Sclerosis of the Columns
of Tiirck. — Primary Symmetrical Lateral Sclerosis. — ^Amyotro-
phic Lateral Spinal Sclerosis. — Progressive Locomotor Ataxia. —
Sclerosis of the Columns of Goll. — Disseminated Inflammation
of the Spinal Cord. — Secondary Inflammation and Degeneration
of the Spinal Cord. — Non-Inflammatory Softening of the Spinal
Cord. — Tumors of the Spinal Cord.

SECTION III.

CEREBRO'SPIKAL DISEASES.

I.— Htdbophobia, ....... 642

II.— Epilepsy, ........ 603

in.— Conttlsite Tbkmob, ...... 696

rV.— Chorea, . .708

V. — ^Athrosis, ........ 722

VL— HTSTlBLi, 730

CONTENTS. 11

CHAP. PA6B

VII. — Htstbboid Affections, . . . . . .745

Catalepsy.— Ecstasy. — Hystero-EpUepsy.

VIII. — Multiple Cebebbo-Spinal Sclekobis, .... 772

IX. — Pakaltsis Agitans, ...... 783

X. — Akapbisatio Paralysis, ...... 786

XL— Exophthalmic Goitre, ...... 791

SECTION IV.

DISEASES OF THE PERIPnEBAL NERVOUS SYSTEM.

I. — Neural Congestion, ...... 802

II. — Acute Neuritis, ....... 804

III. — Chronic Neuritis— Neural Sclerosis — Neural Atrophy, . 807

IV.— Tumors of Nerves, ...... 810

V. — Neural Paralysis, . . . , . * . .811

Facial Paralysi«». — Paralysis of Third Nerve.
VI.— Neural Spasm, ....... 820

Facial Spasm. — Torticollis. ,

VII. — Neural Anaesthesia, ...... 823

AnsDsthesia of Cutaneous Nerves. — ^Anaesthesia of the Fiflh Pair.
VIII. — Neural Hyper.esthesia (Neuralgia), .... 827

Neuralgia of the Fifth Pair of Nerves. — Cenrico-Occipital Neural-
gia.— Cervico-Brachial Neuralgia. — Dorso-Intercostal Neural-
gia.— Lumbo-Abdominal Neuralgia. — Crural Neuralgia. — Sci-
atica.

SECTION V.

TOXIC DISEASES OF THE VERVOVS SYSTEM.

I.— Plumbism, ........ 838

IL — Alcohousm, ....... 848

III.— Bromism, ........ 867

IV.— Hydraroysm, ....... 873

v.— Arsenicism, ...••... 875

LIST OF ILLUSTRATION'S.

2.
8.
4.

9.
10.
11.
12.
18.

14.
15.
16.
17.
18.
19.
20.

21.

22.
28.
24.

25.
26.
27.
28.
29.

PAOS

CKPHAL0HJE3C0METIR,

Hammond^

.£BTBI8I01fITIR, .....

((

L0MBAED*8 ThKRICO-ElICTRIC PiLI,

Dthamoicktir,

Malhieu,

Dtvamoosaph, .....

DucHKVNi's Trocar, .

Hammond^

&roHRiR*8 Battery, . . . .

Threi Cells in niu^ ....

((

Miliary A.neurism of Brain, .

B<mchardy

" " "...

Hammond,

ATHEROMATOrS ArTERY Of BrAIN,

DL40RAX EXPLANATORY OF PlRALTBIS IN CaSSS

Diagram explanatory of Crossed Paralysis, .

Cerebral Arterlu. Thrombosis,

Hevbntr, .

124

Cerebral Capillary Embolism, .

Virchow,

142

it it tt

142

Cerebral Convolutions,

Broea,

185

Agraphia, .....

Hamnumd,

198

Dynamographic TRAaNO OF PATiE.vr affected with

MuLTiPLB Cerebral Sclerosis,
Dynamographic Tractno of Patient affected with

Multiple Cerebral Sclerosis,
Mauonant Tumor of Brain,
Aneurismal Tumor of Brain,
Intellectual Insanity, .
Emotional Insanity,
Acm Manla, with Mental Exaltahon,

" " " Depression, .

U tt it it it

Dynamographic Tracing of Patient affected with
Gbmbal Pakalysis,

28u

281

Oti,,

296

Prof, W. R Smith,

808

Hammond,

884

841

852

854

»t

855

858

14 LIST OP ILLUSTRATIONa

no. PA6B

'iO. Fac-timile or Writino of General Paralttic, Hammond^ . . 859

31. General Paralysis, . . . *' . . .361

32. Idiocy, " . . 862

83. Demeotia, ..... "... 868

34. Morbid Anatomy in Certical Pachtmeninoitis, Joffroy, . 480

35. Detormity caused by Certical Pachymeningitis, Charcot, .481

36. Deformity caused by Chronic Spinal Meningitis, Hammond, 488

37. Spinal Cord in Intantile Spinal Paralysis, Charcot, . . . 469

38. " " " " " " . " . . 459

39. " ** " " " "."... 460

40. Altered Nerte-Cells of Cord in Infantile Spi-

nal Paralysis, " . . 462

41. Muscle in Infantile Spinal Paralysis, Hammond, . . 468
42 *^ ** ** ** '* . " . . 468

43. " u 4i u «« "... 463

44. " " *• " " . " . . 464

45. " t« »t a u "... 464

46. " " " " " . " . . 469

47. " a u «t t« ^ "... 469

48. Atrophy of Muscles in Spinal Paralysis of

Adults, . . . " '. 479

49. Atrophy of Muscles in Spinal Paralysis of

Adults, ..... "... 489

50. Patient with Pseudo - Hypertrophic Spinal Pa-

ralysis, . .... " 493

61. Patient with Pseudo - Hypertrophic Spinal Pa-
ralysis, .....

52. Glosso-Labio-Larynoeal Paralysis,

53. Writing of Patient affected with Glosso-La-

bio-Laryngeal Paralysis,

54. Glosso-Labio-Larynoral Paralysis,

55. " " " " . .

56. Prooressite Muscular Atrophy,

57. " " "...

58. " " " . .

59. " " "...

60. Spinal Cord in Glosso-Labio-Larynoeal Paraly-

sis, .....

61. Progressive Facial Atoophy,

62. " " "...

63. " " " . . .

64. Muscular Fibre in Progressive Facial Atrophy

(Longitudinal Section — ^normal), . . Hammond, . . 561

65. Muscular Fibre in Progressive Facial Atrophy

(Longitudinal Section — abnormal), . " . .661

««

498

«i

606

((

607

508

509

. . 620

Ducltenne,

. 522

Friedreich,

523

Duchenne,

. 625

Charcot,

637

Lande,

. 647

{{

647

66.

67.

68.

69.

70.
71.
72,
78.

74.

75.
76.

78.
79.

80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.

LIST OP ILLUSTRATIONa

Muscular Tisbuk in Pbooressite Facial Atropht

(Transrerse Section — ^normal), Hammond, .
MrscuLAR Tissue in Pbogbessits Factal Atropht

(TransTerse Section — abnormal), ** .
Dllgrax ezflanatort of Anjbsthxsia in Lesions

OF €k)RD, ..... "
SscnoN OF Spinal Cord in Sclerosis of Lateral

CoLCXNS, ..... Charcot, .

SscnoN OF Spinal Cord in Lateral Sclerosis, **

it ti (t {( ti tt (( It

Section of Medulla Oblongata, . . ^*

Deformitt in Autotrophic Lateral Spinal Scle-
rosis, ...... ** .

Section through Medulla Oblongata in Autotro-
phic Lateral Spinal Sclerosis, . . ** .

Writing of Patient with Locomotor Ataxia, Hammond,

Dtnamographic Tracing of Patuwt with Loco-
motor Ataxia, . . . . "

Dtxamographio Tracing of Patient with Loco-
motor Ataxll, .... " .

Superior Extremity of Healtht Humerus, Charcot,
" " " Diseased Humerus of Pa-

TiENT WITH Locomotor Ataxia, . . " .

Transterse Section of Spinal Cord, . Lockhart Clarke,

Longitudinal Section of Spinal Cord, **

Section of Spinal Cord in Locomotor Ataxia, Pierret,

Sclerosis of Columns of Goll, " .

U ti ti tt it ^ ^ <t

u tt tt tt tt ^ ^ ^ tt ^

u tt tt tt tt tt

Tumor of the Spinal Cord,

«( t4 tt tt tt

tt tt

Cortical Substance of Brain in Htdrophobia,
Xuclei of Pnbumogastrio and Htpoglossal

Krrtes in Htdrophobia, .
Root of Pnrumooastric Nerve in Htdrophobia,
Keuboglia-Cells of Cord in Htdrophobia, .
Athrosib, .....
" (after Photograph from Dr. Hubbard),

** WITH ImBECILITT,

CONTEACnONS IN HtSTBRIA,

Charcot,
tt

Leydcn, .
Hammond,

92.
9S.

94.
9S.

96. " WITH Imbecilitt, . .Dr. Clay Shaw,

97. CoNTEAcnoNS in Hysteria, Charcot,

9ft. tt tt a . . . **

99. Catalxfst (after Photograph ftt)m Dr. Earlj), Hammond,

PAOS

651

551

554

678
678
678
578

576

581
690

691

691
601

601
605
606
612
617
617
617
617
686
686
689
656

657
658
658
724
727
729
787
745
760

LIST OF ILLUSTRATIONS.

rra
100.
lOL
102.
108.
104.
105.
106.
107.

108.
109.

Catalepsy (after Photograph from Dr. Early),
Ecstasy, ....

Hystebo-Epilepsy, ....

Hammond^

Boumevillej

Hammond^

Charcot,

" " • . . . Boumeville,

Writing of Patient with Multipub Cerebro-
spinal Sclerosis, .... Hammond,
WiClTiNO or Patient with Anapeiratic Paralysis, ** .
Exophthalmic Goitre (after Pl\ptograph from Dr.
J. B. CrawfordX .... " .

PAOS

760
760
766
767
769
770
771

781
788

794

DISEASES OF THE NERVOUS SYSTEM.

INTEODITCTION.

THE ISSTBUMENTS AND APPARATUS EMPLOYED JN THE DIAGNOSIS
AND TREATMENT OF DISEASES OF TffE NERFOUS SYSTEM.

Dt?iB.iSE8 of the nervous system, like those of the heart, lungs, and
Unrtix, require special means of investigation and treatment. In no
department of medical science has progress been more decided duriiig
'the laat decade than in that class of affections considered in this trea-
ptase, mtid undoubtedly a great deal of the advancement is due to the
Instruments and iipparatus by which scientific research in this direction
has become practicable.

In the present chapter I propose to describe the instruments and
l^ftpparatus employed in the diagnosis and treatment of diseases of the
[ nervous svstcn?. and to explain the methods by which they are used.

THE OrrtTUALMuSCOPE.

The ophthalmoscope consists essentially of a concave mirror perfo-
nit€fl in the centre, and of a double-convex lens. Several modifications
of ibts arrange me nt are in use, but the simplest instrument is, in my
ifpiniofi, the best for ordinary use, and this is Liebreich's, though, when
Teiy great exactness is required, as, for instance, in determining the
idepih of an atrophic excavation of the optic disk, Dr. Loring's ophthal-
iimsscopo is far preferable to any other.

Liebreich^s ophthalmoscope consists of a polished steel mirror about

\ mud three-quarters inch in diameter, concave, and perforated in the

by a hole about the one-twelfth of an inch in diameter. The

\oi this aperture are beveled, so as to afford as little obstacle as

^poivible to the passage of the rays of light to the eye of the observer.

Tbo mirror is set into a bronze ring with a handle, and there is

fttlaebed also to this ring a clip for holding a concave ocular lens,

18 DISEASES OP THE NERVOUS SYSTEM.

which in some conditions of refraction, either in the eye of the patient
or that of the observer, is necessary in order to produce the requisite
divergence of the parallel rays emanating from the patient's eye, and
thus render the image of the fundus distinct. A direct image is thus
obtained. The lamp, which should furnish a steady flame, is placed on
the side of the patient's head corresponding to the eye to be examined,
and the eye of the observer very close to that of the patient. This
process gives a very satisfactory view of the fundus with the optic disk
and retinal vessels, but requires care, and is more difficult than that by
which the inverted image is obtained.

In this case the observer illuminates the fundus virith the ophthal-
moscopic mirror, and then interposes between the mirror and the eye a
double-convex lens which he holds lightly between the thumb and
finger, resting the ring-finger on the forehead of the patient, so as to
make the hand steady, the little finger being disengaged so as to
be employed in raising the eyelid' if necessary.

The object-lens should have a focal distance of about two inches,
and it should be held so as to bring the focus on the pupil. The lamp
is placed behind and a little to one side of the eye to be examined. In
order to see the optic disk, the patient is told to look at the ear of the
observer on the side opposite to the eye being examined. In this way
the axis of vision is directed inward, and the optic disk readily brought
into view.

These examinations are made in a room lighted only by the lamp
used in the processes. It is sometimes necessary to dilate the pupil
with atropia, in order to obtain a view of the disk, but experience and
tact will generally enable the observer to dispense with this rather dis-
agreeable procedure.

Ophthalmoscopic examinations require the observer to possess a
very thorough acquaintance with the anatomy of the eye,. and also with
the science of optics. Unless these qualifications are enjoyed, it will be
much better to send the patient to a competent ophthalmic surgeon for
an examination than to rush to 'hasty conclusions based on the most
thorough ignorance. The real value of ophthalmoscopy in diseases of
the nervous system is in danger of being disregarded through the scio-
lism of pert pretenders, who read papers and write memoirs without ever
having seen the optic disk to recognize it.

Bouchut * gives the following list of abnormal conditions which are
of importance in the diagnosis of diseases of the nervous system :

Papillary congestion ; peri-papillary congestion ; papillary anaemia,
partial or general ; phlebo-retinal flexuosities ; venous pulsation in the
retinal veins ; dilatations of the retinal veins ; retinal varices ; phlebo-
retinal haemostases ; phlebo-retinal thromboses ; phlebo-retinal aneu-

* " Du diagnostic des maladies du syst^me nerveux, par Tophthalmoscopie,** Paris,
1866, p. 15.

INTRODDCTIOV.

; luErJiorrBSJBnhto the retina and choroid. The diseases in which
fcstfnakB opht ho hnoscopy is valuable as a diagnostic means are— the
aevrral varieties of cerebral meningitis ; cerebral hiemorrhage ; chronio
encephalitis ; cerebral softening ; meningeal haemorrhage ; chronic hy-
drocephalus; tumors of the brain ; contusion, commotion, and compres-
lion of the brain ; general paralysis ; atrophy of the brain ; chronic
pjelitia ; locomotor ataxia ; tetanus ; epilepsy ; essential convulsions ;
ity^ and several others of leas importance.
To these may be added cerebral congestion, general and partial ;
cerebral aDasmia ; and the various forms of sclerosia affecting the brain
And spinal cord.

CEPUALOHJBBCOMETEK.

Although this instrument is intended for experiments on the h>wi r
animala, it enables us to arrive at very definite conclusions relative to
the condition of the cerebral circulation. I first described it in a paper
Mjd before the New York Medical Journal Association in 1868, and
rtly afterward published in the New York Medical Gazette.^ It
was devised in somewhat different form, independently of each other,
by Or. R Weir Mitchell and myself, his being made first in point of
tim«. The instrument consists of a brasa, or iron^ tube nickel^plated^
liich is received into a round hole made in the skull with a trephine.
h ends of this tube are open, but into the upper end is secured
another brass or iron tube, the lower opening of which is closed by a
piece of very thin eheet India-rubber, and the upper opening by a brass
capy into which is fastened a glass tube. This inner arrangement con-
colored water. To this glass tube a scale is affixed,
is second tube b screwed into the first till the thin India-rubber
upon the dura mater, and the level of the colored water stands
0^ which is in the middle of the scale. Now, when the quantity of
blood in the brain is increased, the liquid rises in the tube, being pressed
upward by the elevation of the thin rubber closing the lower opening ;
when the quantity of blood is lesseiied, the liquid falls by its own
gravity*

The various parta of this instrument, as made by Mr. Ford, of this
eity, are shown in Fig. 1 (a, the first tube, which is to be screwed
into the opening in the skull ; ft, the second tube, closed at the lower
iCtd ¥rith thin sheet -rubber and containing the colored water j c, the
Qip to which is cemented the glass tube ; tf, the wrench for securing
ti© first tube into the opening in the skuU ; «, the instrument with
aU its parts in their places).

It was by this instrument that I was enabled to demonstrate, in the
mtmi conclusive manner, that during sleep the amount of blood circu-
in the cerebral vessels is much less than during wakefulness, to

' AUo Journal i>f FtfMh^Ual Medicint^ Jonaarj, lSd9, p. 47.

In 1858 by Dr, Sieveking,* of London. Its value in cases of
ib«»rraltoos of sensibility depends upon the fact^ ascertained by Dn E,
IL Weber, that the capability of distinguishing two impressions, made
.upon the skin simultaneously, varies in different regions of the body
according to the distance they are apart. In sensitive regions, as the
end of the finger, the two points of a pair of dividers can be distin-
guished at about the twelfth of an inch apart, while in the middle of
ihe back only one point is felt, though they are two inches apart. In
accordance with this principle, the festhesiometer is used to determine
the sensibility of the skin in various diseases, it being well known that
this is subject to variation.

Thus, when the sensibility is tntaot, two points, touching the back

pf the hand at the sarae time, can be distinguished as two points when

^parated an inch* If, in examining a patient, we should find that,

two points were two inches apart, the patient felt but a single

II, we should know that he had lost sensibility in tlie cutaneous

nerves of that part of the body.

Dr* Sieveking^s aesthesiometer is nothing more than a beam-com-
pass. It consiMs of a rod of bell -metal four inches in length, graduated

Fio. 3.

a. TlY3lA3r9C « co»

)Atif tmd tenths of an inch. At one end is a lixed steel point ;
"^•otWr f i«wl point is made to slide upon the beam, and can be fixed at

' Btiikk attd F^rtitpt i/er/;<».C%t>wiytW Bmew^ Januwy, 185S> p. 281.

22 DISEASES OF THE NERVOUS SYSTEM.

any distance from the first by a screw which works at the top of the
slide.

In 1861 * I described an aesthesiometer which I believe was the first
used in this country. It consisted of a pair of dividers, to one arm of
which the arc of a circle, in brass, was affixed. This arc was divided so
as to measure tenths of an inch. A short time since, I suggested to
Mr. Stohlman, the instrument-maker, a modification of this instrument,
which for convenience is, I think, superior to all others. This, as
closed, for the pocket-case, and open, as in use, is seen in the accom-
nying woodcut (Fig. 2),* and need not be further described*

The minimum normal distances at which the two points of the
aBsthesiometer can be distinguished in different regions of the body are
stated in the following table : *

Point of the tongue i a line.

Palmar surface of the third finger ^ . 1 **

Red surface of the lips 2 lines.

Palmar surface of second finger 2 **

Dorsal surface of third finger 8 *'

Tip of the nose 8 **

The palm over the heads of the metacarpal bones 8 **

Dorsum of tongue, one inch from the tip 4 **

Part of the lips covered by the skin 4 "

Border of the tongue, an inch from the tip 4 "

Metacarpal bone of the thumb 4 "

Extremity of the great-toe ... 5 "

Dorsal surface of the second finger 6 "

Palm of the hand 5 **

Skin of the cheek 6 "

External surface of the eyelids 6 **

Mucous membrane of the hard palate 6 **

Skin over the anterior surface of the zygoma 7 "

Plantar surface of the metatarsal surface of great-toe 7 **

Dorsal surface of the first finger 7 "

On the dorsum of the hand over the heads of the metacarpal

bones 8 "

Mucous membrane of the gums 9 "

Skin over the posterior part of* the zygoma 10 "

Lower part of the forehead 10 **

Lower part of the occiput 12 **

Back of the hand 14 "

Neck under the lower jaw 16 "

Vertex 16 "

> " A Clinical Lecture on Chronic Myelitis," delivered in the Baltimore Infirmary,
March 16, 1861, American Medical Timea^ June 16, 1861, p. 879.

• First described by me in the Journal of P»ychological Medicine^ October, 1868, p.
830.

• This table is quoted from Miillcr's " Physiplogy," translated by Baly, London, 1840,
p. 762.

INTRODUCTION.

km oTvr tuc patt lin. ,...,.......,

** " ncmm .., ,. / 18

** ** acromion _._.,.. , 18

The leg, new the knee und foot^ 18

Doreuin of the foot, near the toes. . , , , ♦ 18

The Akin orcr the eternuiD. . *.. » . .,♦ 20

** ** five upper vortebrte, 24

** ** f^pine near the occiput. » 24

** in the lumb&r region. ,*..,, ,^« • . 24

" *• middle of the neck 30

** over Uie middle of the back. . SO

The middle of the arm. . .* , 80

" " thigh 80

lines.

TMERMOMETEB,

The thermometer is of use for the purpose of determining variatioiis
of temperature in different parts of the body. It should be graduated
in tenths of a degree, and be held upon the part subjected to examina-
tion, so long as the mercury continues to rise or fall* Comparative de-
temunjitiona must be made under precisely similar conditions.

BEC<^C£REL^S BISKS.

By means of these little instruments very sb'ght variations of tem-
aturc can be ascertained. They consist of an extremely thin plate
^of copper about the size of a half-dime, soldered to a thin rod of bia-
muth. This latter is contained in a small tube of hard rubber furnished
with a handle. The disks are two in number, and by means of delicate
silk-oovr*rL*d wires are in coinmvmication with the poles of a galvanom-
eter. If a lower extremity, for instance, is subjected to examination,
one of the disks is placed upon it and the other upon the correspond*
i ifig part of the other limb. If the temperature of both limbs be the
I iunei the needle of the galvanometer remains quiet ; if either be
' wmrmer than the other, the needle is deflected to the north or south
»cicx)nling AS one or the other limb has the higher temperature. By
tills apparatus very much less than the hundredth of a degree of tem-
[ peraturc* can be determined with absolute accuracy/

l>a. LOMBAKD'H THKHMO-HLECrrElG WFFKKENTIAL CEALOBIMST^B.

For determining differences of temperature nothing equals this in-
ilnilDeiiti both for eiiactness of results and facility of application.

Il eovmsie^ as shown in the accompanying cuts (Figs* 3 and 4), of

* &v mt- ** Iteu^r on the Pathotngv and Treatment of Organic Infantile Paralvdis/'
ia Jtanm^ ot Psttchalfmuxtt MfiVtcme^ No. L J^Ij* 1867, p, 68.

INTRODUGTIOK.

ne the bobbins and four little cups of mercury by means of which iUt-
oonnections are made, an J the resistance of the thenno-electric cur-
rent increased or diminished, according as it is necessary to make the
needle more or less delicate in its indications.

There are two themio-electric piles j one of which ^^o* ^

b represented in Fig. 4, and which, for convenience of
manipuistiou are furnished with handles. These piles
are connected by their positive and negative poles, and
tbf? other positive and negative poles are connected
with the stanchions seen on the ebonite plate of the
galvanometer.

Having lowered the little metallic fork at the farther
extremity of the bar ov^er the ebonite plate, into the cup
of mercury immediately under it, the apparatus is ready
for use. The delicacy is increased by lowering one or
two, or all thrtie of the others, each one being in con*
nection with the bobbin iminediatoly opposite to it, and
which, when the fork is out of ih^* mercury, is included
to the circuit, and henoe has the efFcet of increasing
Ibe reiistancc. In the figure all the forks are repre-
8«it4Kl M down.

To nuake an observation the thermo-electric piles
placed on« on the part the relative temperature

which it is desired to know« and the other on the
sound part. If the pile in connection
uhion nearer the comer of the ebonite
plate is in contact with the hotter part, the needle will
h * " unite the north. If the other be the hotter,
ti . ' will be defected to the south. The extent

of |j>e deflection indicates the relative difference in

drediha of a degree centigrade. It is to be remembered that the
trui&ent must be placed on a firm table or stand, and must be so
armngf^d that the end of the scale to the light of the cut points to the
north ; the ebonite plate will therefore be at the south end, and the
golvaticiiiictcr utH'dle points to the east J

\\' apparatus tif Dn Lombard^s it is easy to make relative

deterti h of tempcniture in a minute or two, and with great ex-

actoesi and delicacy.

THE DTXAMOICSTEE.

Several forms of an instrument for measuring the strength of pa-

^ts havrt been devised. The best and most gencj-ally applicable is

at of XL Mathieu, an instrument-maker of Pari^, It is very simple,

A fullrf cIcsifHption of thU tnfitram^ni and directloiw for iu uac, the rftder if

k4 tn th.. ff*-*f*Ah \fr<lu,tl Journal lor ISTft.

DISEASES OF THE NERVOUS SYSTEM.

and for ascertaining the strength of the hands leaves nothing to be
desired.

It consists, as is shown in the cut (Fig. 5), of an elliptical steel
spring, to which is attached a semicircle of gilt brass, upon which a
scale is marked. An indicator, terminating at one end in a cog-wheel,
is capable of being moved freely around the arc of the circle by a steel
arm, upon one side of which, cogs, fitting into those of the indicator,
are cut. One end of this arm (the lower) touches the elliptical spring,
when the indicator points to the zero of the scale ; a brass sheath upon
the under side of the scale keeps this arm in place, at the same time
allowing it to move freely.

Pio. 5.

When the dynamometer is taken into the hand and pressed, the
two sides of the spring are approximated, and the steel arm with the
cogs, being pushed by the lower side of the spring, turns the indicator.
One great advantage of this instrument is that, when the pressure is
taken ofF, the indicator does not return to zero, but remains at the point
to which it has been carried by the muscular power of the individual.
We are thus enabled to see the extent of his strength, after he has
made his effort, and do not have to watch him while he is using the
instrument. It will also bo seen that this dynamometer can be used to
measure tractile force; for, if two hooks with cords attached be fastened
to the spring at the points a and ^, traction on the cords will approxi-
mate the two sides of the ellipse, and thus push the steel arm so as to
move the indicator as before.

THE DYNAMOGBAPH.

This instrument, which is of great value in the diagnosis of diseases
of the nervous system, is shown in Fig. 6.

It consists of the dynamometer B B, to which a toggle-joint, mov-
ing a steel rod, is attached. This steel rod plays through a hole in the
end of the elliptical spring and moves the lever which raises the pencil
D. At A is a screw which varies the point at which the rod touches
the lever, and thus increases or lessens the delicacy of the indications.
C is a silvered plate upon which the paper is fastened by clips. To the

LNTRODCCTION.

rtr part of this plate, a strip of gilt brass, with cogs cut in it, is at-
bed. E i« a gilt-brasa box containing a watch-movement like that
of the sphygmograph. A cog-wheel which projects above the upper
aide of this box fits into the cogs on the plate which carries the paper.

Fia. &

wheel for winding up the clock-work, and the lever for stopping it
suiting it tn motion, are not seen in the Bgure, they being on the
'iippositc side of the box.

To »et the instrument in action, the sphygmograph movement is at-
tached to the dynamometer at A, The clock-work is then wound up,
and th© plate holding the paper placed in the groove on top of the box
E, The dynamometer is then grasped by the hand and squeezed firm-
ly ; the lover is thus moved, and the plate with the paper is carrieil
by the cog-wheeL As it moves, the pencil traces a line on the
ipcT, the height and regularity of which depend upon the firmness and
with which the d>Tiamometer is pressed. As seen in the cut,
» plitto with the paper is in motion, and has about half completed its
taounc. The patient should not look at the paper while using the in-
nenU
Tli« dynatnograph, therefore, writes down the muscular power and
* of the individual, and likewise indicates the perfection of what it*
fttimcis called the muscular sense. A person in good health wnll
ke a straight lino with the pencil. If there is paralysis of the mus-

28 DISEASES OF THE NERVOUS SYSTEM.

cles of the arm, or incoordination to the slightest possible extent, the
line will be irregular. The papers used may be marked with the date
and the name of the patient, and thus a record of his condition is pre-
served.

The pencil should be of the very softest lead, and the paper should
be rough and unsized*'

DUCHBN3JE's trocak.
This very useful little instrument is shown in Fig. 7. It is intro-

Fio. 7

duced open as at a. When it has perforated the muscle under exami-
nation, the small button at the under part of the handle is pushed for-
ward; this propels a half -cylinder of steel against the shoulder at the
end of the trocar, and thus a small piece of muscle is detached and
caught in the cavity. The lower figure, ft, represents the instrument
ready to be withdrawn. By drawing the button back, the bit of fibre
can be taken out, and is then ready for microscopical examination.

ELECTRICAL APPARATUS.

The electrical apparatus required in the diagnosis and treatment of
diseases of the nervous system must be of two kinds: one for furnish-
ing the primary or galvanic current, the other for yielding the induced
or faradaic current. Among the machines of the first category are
those of Stohrer, which are now made very satisfactorily by the Gal-
vano-Faradic Manufacturing Company of New York. An idea of this
battery (thirty-two cells) will be obtained from the accompanying
woodcut (Fig. 8). The case is represented as broken away in front, so
as to exhibit the internal arrangement. A combination of Smee's cells
is manufactured by Dr. Jerome Kidder, and constitutes a good battery,
and Daniell's cells can be obtained of any electrical-instrument maker,
and arranged so as to form a battery for medical purposes.

Some time since, my attention was drawn, in another connection
altogether, to the simplicity and efficiency of Hill's cell as a generator
of a constant and most equable galvanic current. After an examina-

* The first account of the U8e of the dynaraograph was given by myself in the Journal
of Piychohgical Medicine^ January, 1868, p. 139.

LVTRODUCTION,

ti Fi ot 3t8 coDStmction and action, I was satisfied that, for medical pur*
|Kises. it \%a*» vastly superior to every other form of element wivich had
rume under ray observation. At my suggestion, the Galvano-Faradic

Fit* S.

iring^ Company, of this city, has constructed, under the supcr-
of Mr. Bart let t, a permanent battery, which, for office or
itftl ume^ h o( ineatlmuble value. When erected it becomes, as its

DISEASES OF THE NERVOUS STSTEIL

name implies, a pc»rmaneM fixture* Several of these have been made j
one for myself, of one hundred elements, leaves nothing to be desired
when used with Brenner*s operating-table*

The cells used for this battery have been hitherto applied to te-
le^aphy. Thej possess^ however, in an eminent degree, the peculiar
qunlities that are essential for a galvanic battery for therapeutic pur-
poses* The battery itself is simple in construction, easily managed,
exceedingly economical, utilizing almost all the materials consumed-

Each cell contains about half a gallon of fluid, A disk of sheet-
copper is laid flat on the bottom of the cell. To the under side of this
is affixed a copper wire, covered with gutta-percha. The copper sheet
forms the negative plate / the insulated wire which rises to the top of
the cell, the posittve pale. Two or three inches below the upper mar-
gin of the cell is suspended, by a brass hanger, a thick, disk-shaped
plate of zinc, concave on the lower side, with a round aperture in the
centre. This is the positive plate* To the hanger is attached a binding
screw, and this forms the negative pole^ Three cells in situ are repre-
fiented in Fig. 9,

.--^

The body of the battery fluid is formed of a solution of sulphate of
zinc. Occasionally, as required, crystals of sulphate of copper are
dropped through the central aperture in the zinc to the bottom of the
fluid. These dissolve, and produce a layer of blue liquid, which covers
the copper. Thus, we have copper in the bottom of the cell, immeraed
in a solution of copper, zinc suspended above, immersed in a white
liquid, the solution of zinc. ( Sm engraving of thei*e cells.) The mode
adopted in other batteries to separate the fluids consists in using a
porous diaphragm, or cup, within, and surrouhding which are placed
dissimilar metals and fluids. The porous septum, it wa^ thought, would
allow the current to pass, and yet prevent the admixture of the diverse
elements. It has, however, been demonstrated that, when two such
liquids, and even two gases, are thus separated, they will invariably be-

INTRODUCTION.

inivt-.i. In this hattery, Mithout the . intervention of any dia-
phm^m, the denser liquid, the blue, remains in the bottom of the cell>
the lig^hter one overflows and re^ts upon it; thus arranged, there is less
Itabitlty to diffusion or mixing than if the two liquids were placed side
by side, in vertical columns, with a porous partition between them*

The central aperture in the zinc plate also admits the introduction
of a hydrometer to measure the density and strength of the liquid. Pro*
viftidn is also made for preventing too rapid evaporation of the fluid,
Tlie occasional addition of a little water, and every three or four weeks
dropping in a few^ crystals of sulphate of copper, is nearly aU that is
roquirod in the management of thia battery. Further directions for
prrparation, tnodutt operandi, and care, may be obtained from the
fcnufacturers.
Of faradaic batteries, those made by Kidder, the Galvano-Faradic
Hsnufacturing Company, and Meyer, leave nothing to be desired.

Although the applications of electricity in the treatment of diseases
I ilie nervous system are not so extensively useful as asserted by some
5rs, it is nevertheless impossible for the physician to treat severe
aHectioos of the kind mentioned without using the agent in some form
or other* This is especially true of those diseases wiiich are character-
iiod by poralysija, in nearly all of which electricity is useful. In atrophic
<lidocil<*rs it is also indispensable, and in many hysterical conditions it is
extreniely valuable.

If only one battery can be procured, the induced or faradaic instru-

H Will be found more gfuierally useful than the primary or galvanic ;

if possible, the physician who intends to treat to the utmost ad-

disoasea of the nervous system should possess both kinds*

CAUTERIZIXG APPAHATUS,

It is often necessary, in^the treatment of diseases of the nervous
ienij to make use of the actual cautery to the spine and other parts
of the body. The instruments formerly employed were very clumsy
thingB made of iron, and, when required for use, heated in a furnace of
somi! kind* The chief objection to iron is, that every time the instru-
BMOt is hf^atod to redness the surface becomes oxidised, and the scale
nmj become loose, stick to the patient^s body, or fall between his cloth-

fa*.

Lstely, instruments with platina tips of such shapes as may be
leqtiij^ have come into general use, and are far preferable to those of
inn. Bering smaller, they are readily heated to redness or whiteness in
a Bltnatifi^s burner where there is gas, or in an alcohol blast -hi mp.

Before using the cauterizing instrument, the skin should be ren*
«lefed aiuesthetic by the ether or rhigolene spray. It is not necessary
to oairy the iipraying to the point of congealing the skin, although
lbt*n; 11 no objectioQ to so doing.

32 DISEASES OF THE NERVOUS SYSTEM.

OTHER IXSTBUMENT8 AND APPARATUS.

Among the other instruments and apparatus required in the diag-
nosis and treatment of diseases of the nervous system are the micro-
scope, the stethoscope, ear-specula, tuning-forks, urinary test appa-
ratus and chemicals, hypodermic syringes, and Richardson's spray
apparatus.

The latter is of use not only, as above mentioned, for rendering
ansBsthetic the part to be cauterized, but for refrigerating the skin in
cases of chorea and other affections.

SECTION L

ISEASES OF THE BEATN.

CHAPTEB I.

CEREBRAL COI^QESTION,

Crkhbiul congestion is of two kinds, which diiTer as regarc!s their
of origin and symptoms. In the active form, there is an increase
itiio amount of arterial blood circulating in the vessels of tho brain ;
in the ^Missivej the quantity of venous blood is augmented. Occasion-
ally the two conditions coexist,

ACTIVE CKB£BBAL COKGKSTIOK

ThiA is much the more common form. Of the eases recorded in my
>kf as ooeurriiig in my private and hospital practice, over 6vc-
I urer© of this description,
Andimly who, however, failed to distinguish the fir>it or iix^nm-mic
recognized eight varieties, all of which may, with advantage, be
aprehended in six, which are appropriately designated from the chief
it!ire characterizing the attack, namely, the apoplectic^ the paralytic^
[ canmilsive^ the mporifc^ the maniacal^ and the aphastCy the latter
A sixth form, which is now, for the first time, systcmaticiilJy ar-
l m the present category. Either of these may occur mth scarcely
momeiit'i warning. Generally, however, there is a premonitory or
, vtftge, the symptoms of which, though well marked, are not peculiar,
Entirely, to any one of the fulIy-establiBhed conditions mentioned.
It is therefore impoasible to predict with accuracy, from the symptoms
,«l ika prodmmatic stage, whether the apoplectic, the paralytic, the
HTulsare, the aoporifte, the maniacal, or the aphasic form, will be
reloped. An attentive study of thia stage should always be made,
3

34 DISEASES OF THE BRAIN.

and active measures taken for the relief of the patient at a time when
success can generally be obtained.

Symptoms. First Stage, Cerebral Hyperjemia. — ^Among the
earliest symptoms of active cerebral congestion, wakefulness is espe-
cially noticeable, and may be for a time the only evidence of disorder
which attracts the attention of the patient. He goes to bed feeling
weary, and as if sleep would very quickly overtake him, but he is dis-
appointed, for he obtains but an hour or two of disturbed slumber,
which is generally broken by unpleasant dreams. During the remain-
der of the night he tosses restlessly from side to side of the bed, his
mind either occupied by the thoughts which have occurred to him
through the day, or else filled with the most preposterous ideas. He
consequently rises unrefreshed, feverish, and ill-prepared for either men-
tal or physical exertion.' So far as the mind is concerned, there is an
inability to give the attention to any subject requiring much thought,
and at times an absolute want of power to get correct ideas of even
simple matters. This is especially seen in those who have arithmetical
questions to solve, or long columns of figures to add up. Indeed, men-
tal labor of all descriptions is not only difficult, but is irksome in the
extreme.

Before long the evidences of intellectual derangement become more
evident. The ideas are confused and without logical arrangement ; the
memory begins to. fail, especially in regard to recent occurrences ; and
there seems to be a special proclivity to forget words, and to substitute
others having a similar sound when pronounced, or appearance ^en
written. The names of persons and places are particularly difficult to
recollect. The judgment is weak and vacillating ; the most strongly-
expressed determination is changed apparently >vithout reason, and
again there may be an impossibility of arriving at a decision in cases
where ordinarily but little reflection would be necessary. Any effort
toward continuous or severe thought increases the difficulties of the
mind) and augments the pain or uneasiness which generally exists in the
head. Illusions, hallucinations, or delusions, may be present, but are
not usually fixed ; and the patient will often laugh at the absurd images
he has seen, or ideas he has entertained not five minutes before. Per-
sons thus affected will frequently reason clearly in regard to apparitions
or voices, of the unreality of which they are fully sensible.

The emotional system participates in the general mental disturbance^
and the passions are thus easily roused into activity by slight exciting
causes. Trifling circumstances produce great annoyance, and the little
every-day troubles of life appear of vast importance. The disposition
accordingly becomes suspicious, peevish, and fretful.

In conjunction with these mental phenomena, there are certain phys-

1 For a more complete account of wakefulness in all its relations, see the anthor's
treatise on " Sleep and its Derangements.'' J. B. Lippincott & Co., Philadelpliia, 18'ZOk

ih COKOESTION.

ptoms of disordered cerebral action. Thiis there are pain, heat,
%• t^liDg of fullness or distention in the head, or the sensation as if a
tight band encircled it. Vertigo is verj*generally complained of, and
ly be HO severe as to prevent the patient moving about. In some
ws headache constitutes the chief feature of the disorder, and is al-
tnoit cxjnstantly present. There are noises, such as roaring, rumbling,
and ringing, in the ears, and occasionally loud reports, such as those
prijduet^d by the discharge of fire-anus. Sometimes there are bright
fl&ahos of light from over-exeitation of the retinji', and at others dark
spots — mvsf'OB volitantes — render the vision indistinct. Ophthalmosco-
pic examination^ which should never be omitted, shows the arteries of
the retina to be increased in number, diameter, and tortuosity, and oc-
c^onally the optic disk is found more or less congested. The conjunc-
tiva are suffused, the pupils are contraotedj there is intolerance of lights
motion of the eyeballs is painful. I^ud noises are likewise dis-
i*able. The face is flushed, the carotids and temporals throb with
more than ordinary force, and there may be involuntary twitching of
one or more of the facial or other muscles. Bleeding from the nose b
not infreljuent.

S<?iisation and the power of motion are usually affected, and gener-
ly, though not always, on one side of the body only. Thus the arm
Of the l<^g feels heavy, and a sensation aa of ants crawling over it, pins
I needles sticking in it, or as if the limb is ** asleep,'* is experienced,
abnonnal sensations may be restricted to the face or the tnmk,
mimitlon with the lesthesiometer shows that the ability to distin-
•^ the two points of the instrument at the normal distance apart is
laa <m the affected side than on the other, and that, thus to get the sen-
flftttoQ of two points, they must be more widely separated when applied
to the fiiseased side than Is necessary for the corresponding parts of the
•cMUid side,

Slight convulsive actions or twitcliings of individual muscles or
^roop9 of muscles arc generally present. Sometimes a few fibres only
mxm affected. The face, and especially the eyelids and angles of the
h, are particularly liable to be thus involved.

muscular strength is also lessened generally, but sometimes the

dBBeuhy is e«pocially noticed in particular muscles, such as the tibialis

or thn deltoid, which, losing a portion of their contractile power ^

Ibo patient to experience an awkwardne^ts in raising the foot, or

iting the arm from the side. The face, however, is rarely affected,

when the muscular power is diminished on all the rest of one side

of the body, and the tongue, when protruded, comes out straight,

td observation will genemlly detect some dilBculty, perhaps slight,

the speech* WoMs are not pronounced with as much distinct-

*9 before, especially when the patient is fatigued, or has been

ng tor aome time. The Unguals and labials among letters are

36 DISEASES OF THE BRAIN.

particularly troublesome, as well as all words which require the nice
management of the end of the tongue for their enunciation. The ar-
ticulation is thick, and sometknes whole syllables are slurred over in a
slovenly way.

The other organs of the body are more or less deranged. The pulse
is unusually slow and full, the appetite capricious, the digestion imper-
fect, the bowels costive, and the mine, scanty and high colored, often
contains oxalate of lime.

The foregoing constitute the ordinary assemblage of symptoms
which are first met with in congestion of the brain. Some of them may
be absent, others so slightly manifested as to escape ordinary observa-
tion, and others, again, so strongly exhibited as to excite the grave ap-
prehensions of the patient and his friends, and to require him to keep
his bed. Generally, however, they are not so severe as to prevent him
attending in a measure to his ordinary avocations, and they may alto-
gether disappear, either spontaneously or in consequence of appropriate
medical treatment.

A spontaneous cure is, however, rare, and, without proper manage-
ment on the part of the patient or his medical attendant, the s^rmptoms
pass sooner or later into one of the fuUy-developed forms mentioned.
Thus, of the cases that have been under my observation, the disease was
arrested at the first stage in about ninety-five per cent, by appropriate
treatment, while there was not a single instance of spontaneous cure.

Second Stage, a. The Apoplectic Form, — Occasionally this va-
riety of cerebral congestion is initial, but ordinarily it is preceded by
the group of symptoms just detailed. In either event the onset is gen-
erally sudden. The patient is perhaps walking in the street, when he
staggers, loses consciousness, and falls. The loss of intelligence and
sensibility is, however, rarely complete, and may last but a few minutes
or even seconds, though sometimes continuing for several hours.

Paralysis, to a greater or less extent, is always present for a time.
One limb only may be affected, or those of one side, or all four mem-
bers. It is never complete, the patient being able to perform some
movements, though not to exert his full strength. The face is rarely
involved, and the patient, though answering briefly when addressed in
a loud voice, speaks indistinctly and with difficulty.

The respiration is loud, slow, but rarely stertorous, and it is not
often that there is puffing of the lips and cheeks.

The pulse is slow, hard, and full. Sometimes the face is flushed,
and sometimes it is unusually pale. The sphincters generally retain
their power.

The senses, though weakened, are often capable of being exercised
by tolerably strong excitations. A bright light causes uneasiness and
closure of the eyelids. A loud noise is productive of discomfort, and a
limb, when pinched, is withdrawn.

CEREBRAL CONGESTION,

■* In oi

power of the mind is greatly loosened, and some faculties are
»itogrthcr abolished. Answers more or less direct are given to simple
tons ptrt in a loud tone, but even moderate intellectual action

Ills to be impossible.

Gradually the attack passes off, leaving the patient in a state af
tuental and physical depression, which may last for several days. The
piuulysis usually disappears, but occasionally it does not, one or more
limba or muscles remaining^ permanently, or for a long* time, disabled.

It sometimes happens, however, that the termination is not i^o favor*
ahliv The vessels may remain congested, serum may be elTused, and
dcmth may result without there being any vascular lesion. Two cases
hare oome under my notice, in which death ensued from this cause in
firvt ftttaeks.

A person w!>o has once had a paroxysm, such as has been describcdt

thereby rendered more liable to subsequent seizures, each one of
Ji Mill further pennanently impairs his mental and physical powers.
Si one case, occurring in my practice, there have been eleven attacks
ia fire years ; and in another^ fourteen in four years. In both of these,
and in several sfimilar instances I have witnessed^ there was paralysis,
which had become mor6 profound with each accession. It is therefore
inex^act to say, as do some writers, that the jiaralysis of cerebral con-
gestion always disappears in a short time.

The apoplectic form of cerebral congestion is more common than
my other of the fully-doveloped varieties, about one-half of all the casee
g of this t\'pe.

b. The Paralytic Form. — Like the apoplectic variety, this may be

unpreeeded by tho premonitory symptoms constituting the first stage,

it usually they have been present. The loss of power or of sensi-

ty, or of both, may be very circumscribe<l, limited to a single group
of iiiQScte^ in the one case, or a small portion of the cutaneous surface
ia ibe other, or one entire side, or both sides of tho body, may be in-
?ohr«d. It differs from the apoplectic form in no essential respect,
that there is no loss of consciousness. Its onset is sudden.
Tht Cortrulitwe Form, — This, like the variety just described,
may ooine on suddenly , or may be preceded by premonitory symptoms.
Tb<5 phenomena of the attack do not generally differ from those attend-
on an ordinary epileptic paro^tysm, except that there is never an
■ttrm, and no peculiar cry, such as is so often met with in pure epilepsy,
Tbrre ia the skamo tonic spasm, followed by clonic convulsions, which
tmj or may not bo confined to one side of the body, and which may or
may not be followed by temporary or long-continued pamlysb. Stupor
Uk^wbe supervenes, but is neither of so long a duration nor so profound
MB in true epilepay.

• In oth^r ca»es, and especially in infants or young children, there ia
fio loaa of consciousness. The pain in the head is intense, the pupils

38 DISEASES OF THE BRAIX.

are contracted and insensible to light, there are vomiting and accelera-
tion of the pulse. The convulsive movements, which may be either
tonic or clonic, or both alternately, are either quite general or confined
to a single limb or even a group of muscles.

This form of cerebral congestion is never developed during sleep,
for then the brain contains less blood than when the individual is awake.
It may occur during stupor induced by certain drugs, constriction of
the neck, or a dependent position of the head ; but stupor is not sleep,
although the two conditions are frequently confounded. Convulsions
occurring during ordinary sleep are never the result of congestion. This
point will be more fully considered under the head of epilepsy.

After the stupor the patient may feel comparatively well, or there
may be delirium continuing for several hours. As in the apoplectic
form, there may be a succession of attacks, and the mind and physical
power of the patient are thereby greatly weakened.

The variety under consideration is, perhaps, more liable to occur in
individuals past the age of forty, though I have witnessed several cases
in quite young persons. It is not often met with in old age, and, when
it is, is generally fatal, probably from secondary lesion. A majority of
the cases of epileptiform convulsions, occurrisg for the first time in
persons over the age of forty, are instances of the convulsive form of
cerebral congestion.

d. The Soporific Form, — ^This form will be more fully described
under the head of passive cerebral congestion, to which condition it is
almost entirely restricted. It differs from the apoplectic form in the
circumstance that the invasion Ls gradual ; and from this and the para-
lytic in the fact that there is no paralysis, although the limbs may be in
a state of general resolution. The chief phenomena are, pain in the
head, dilatation of the pupils, and stupor.

€. The Mania<:al Form. — ^This variety, though not so common as
either of the others, is yet not infrequent. It is characterized by an
accession of mental derangement not materially different from that in-
dicative of acute mania. The delirium is of a very active character, the
eyes are suffused, the face is red, the head hot, the motility active, and
the whole manner, character, disposition, and mental processes, are
changed. During the paroxysm, the patient may commit some act of
violence, and it almost always happens that his combative proclivities
are aroused. He may likewise attempt to injure himself.

The attack may come on with great suddenness. In the case of a
gentleman recently under my charge, it was the result of eating a hearty
meal in a great hurry at a railway-station. A few minutes after his
return to the train, he was attacked with furious delirium, during which
he attempted to injure himself and all within his reach. He was seized
and held, but continued, as far as he was able, to bite, scratch, and
kick, at those who were near him. The paroxysm lasted about two

CEREBKAL COKGESTION,

31*

He then fell into a heavy stupor, from which he did not arouse
hours longer* For several davs his mind was weak, and there
WMS numbness in various parts of his body. Gradually, ho vi ever, he
regauned hia former powers, but ho suffered from occasional confusion
of tbougbt and difliculty of speech, with headache and wakefulness for
0cvend we^k^.

In another case — that of a boy thirteen years of age — it waa oharao-
teri^tvl by paroxysms of maniacal excitement, during which the subject
h' I tx) bite and otherwise to injure those around hbn, indulging

II i I J lie time in the most profane and obscene language. These

scixoros took place about once a week. There was generally a distinct
reooUeotion of all the events which had happened. In several other
CMOS the seizures were the result of malarial poisoning, and were ex-
actly periodical in their occurrence.

Paralysis, :is in the other forms, may be one of the phenomena of

( Tarietj of cerebral congestion.

Death may t^ke place during the attack, or from secondary lesions
aft4*rwaitl.*

What ia called temporary insanity, mania ephemera, or impulsive
ty, generally depends upon cerebral congestion. The subject,

efore, is of vast importance in its niedioo-legal relations.*
/i The Apha^ir* Form. — The inception of this type is usually verj'
eo. Tljere may or may not be the accompaniments of pain in the
bead, vertigo, and confusion of mind. The chief symptom is the iru-
pAimidnl or abolition of the faculty of speedj, and this mfiy be the only
pliwiomenon. A very interesting case is that of Prof. Lordat, which is
graphically described by Trousseau.' The loss of speeoh was at first
coinpU'te, but was entirely'regained in twelve hours.

Several similar instancea have come under my observation. In a
case at this time under my charge, the patient, a lawyer, was suddenly
cieprrred of all power of speech, after passing several hours in very in-
teruie study. There was a little confusion of ideas, but neither pain nor
Tettigo. There was loss both of the memory of words and of the power
of m ockOrdinating the muscles of speech as to articulate. Tliere was
no paralysis anywhere. Recovery was complete in less than six hoiu^

In two eases occurring in my own practice, the patients were sud-
4mAj reodiered aphasic by inhalation of the nitrite of amyl. llie effeot

* The whole fiml^cct of oerebrsl oongoitkm has been well cooBidtsred bj Calmeil, fa hla
♦*Tr»iti lie* M^Udica InflftmniAtoires du Cervcau.'^ PariB, 1859.

■ See a memoir by the author, entitliMl " A Medico-Legal Study of the Caw of l><m1el
FarUnd,'* m the Journal of Pttt^htJ^^qitul Medicine for Julj, 1870, Xho publiaht-J
elf hf D. Appletoo k Co, Sew York, 1870. Al»o a pap«r oa " Morbid Impiil^e/'
i%^fAoi«fif*d nnd Mr^ico^I^e^ Jovmal^ Augttsrt^ 1874.

* *'Leclitne» ou Cliiucal Medidne^^^ etis. Tmnabl^il bj P. Victor Banre, M. D Lou.
i1M6|JkSI9.

40 DISEASES OF THE BRAIN.

continued for half an hour in one case, and for nearly an hour in the
other, after all the other phenomena from the amyl had entirely disap-
peared.

The subject of aphasia will be more fully considered in the subse-
quent part of this workr

Third Stage. — ^This period may be considered as beginning after
the immediate effects of the paroxysm, whether it has been of the apo-
plectic, paralytic, convulsive, maniacal, or aphasic form, have passed oif.
It is characterized by feebleness of body and mind, by gastric or intes-
tinal derangement, by pain in the head, with transient attacks of ver.
tigo, and occasionally by numbness and slight paralysis of one or more
of the limbs. Many of the symptoms met with in the first st^ge are
again found in this.

But the principal phenomena are those connected with sccondaiy
lesions, such as inflammation, abscess, softening, and adventitious
growths of various kinds. These will be considered under their proper
heads.

It must not be forgotten that one circumstance always exists, and
that is, the proclivity to other paroxysms of some one of the fully-de-
veloped forms.

PASSIVE CEREBRAL CONGESTION.

This condition is the result of causes which increase the amount of
venous blood in the brain. It is more commonly met with in old per-
sons and in those of feeble constitution. Women are more frequently
affected than men.

Symptoms. First Stage. — As in active cerebral congestion, there
is a premonitory stage, the symptoms of which are similar to those pre-
« viously described. There is, however, a tendency to stupor, and the

other phenomena are, in the main, less strongly marked. Vertigo, pain,
illusions, hallucinations, and delusions, are nevertheless generally pres-
ent at one time or another. But the stupor, or tendency to somno-
I lenoe, is the most prominent feature, and the sleep, even when oompara-

i tively natural, is attended with dreams unpleasant or even frightful in

character.

The degree of congestion may be suddenly increased, or, what is a
more probable sequence, there may be effusion of serum, and then in
either case the second stage, exhibiting itself as in the apoplectic, the
paralytic, the convulsive, the soporific, the maniacal, or the aphasic
form, results.

The proportion of cases of passive cerebral congestion which pass to
the second stage is greater than in the active form of the affection, and
it is accordingly a more serious disease.

Second Stage, a. The Apoplectic Form, — ^In this variety the
onset of the affection is sudden, like that of active cerebral congestion.

CEREBRAL C0NGE8TI0K.

The Io«8 of consciousness is generally complete, the face is red, the
pupils are dilated and insensible to lig-ht, the respiration is stertorous,
Jind tho faeces and urine may be passed involuntarily. The action of tho
heart is slow and feeble, and the pulse corresponds to these facts. Pa-
ralysis may be general, or confined to a lateral half of the body*

If sensibility returns, there are pain in the head, vertigo, tinnitus
aurium, generally some embarrassment in the speech from lingual paraly-
sis, and more or less loss of the power of motion in other parts of the
body« There %vill ako be general or partial anaesthesia* As the condi-
tioii of the patient improves, these symptoms generally disappear.
Deathi however^ is not an infrequent sequence.

This form of cerebral congestion is most common with elderly per-
M>ri5, and appears to be particularly apt to attaok old women.

6. The I*aralytic Fornu — Tliis does not differ essentially from the
apoplectic form, except that there is no loss of consciousness, tho pa-
rmlv<is ronstituting the main symptom. It may be either sudden or
gradual in iis inception,

c. The CoHvuiMve J^ortn. — This may not differ materially from the
coiivutsiTe form of active congestion, except as rogards increased length
of ibe fit and prolonged stupor. Generally, however, there is a repeti*
ticm of the seizures^ and I am led to believCi from my experience, that
there ia a greater tendency to biting the tongue* Paralysis is a more
sequence, and is of longer duration, and tho mind appears to
seriously and at an earlier period,

dw Th$ Scpor^ Form, — The first symptom observed is commonly
m genexal numbness and indisposition to muscular exertion^ The drow-
siiieas, which has probably been present to some extent, inoreasea and
aooa becomes the most notable feature. At first, it is easy to rouse
the patient from this stupor, but it gradually boeomes more profound
ami orerpoworing, until at last a persistent comatose concUtion is
FMclicd. The faculties of the mind may, in tho earlier stages, be ex-
alted toto a moderate degree of activity ; but with the advancing coma
tbey are no longer capable of being manifested. The cutaneous senai-
bUily beoomes less and less, the urine dribbles from paralysis of the
Usdtter and its spliincter, and the bowels, if not obstinately constipated,
AEaw their oooteuts to pass involuntarily* With these symptoms, the
pvpQs aie dilated, and, as long as sensibility exists, pain in the head is
aoDiplatsied of. The faculty of speech is impaired at an early period,
bol^ sJtiKmgh the tongue is restrained in its movements, there is no
iiOtttsl paralyais of this or any other muscle. This condition may last
for several weeks^ and, though recovery occasionally takes place, this is
tiewir eomplfite, Doath is the more usual termination.

. Ths Maniaeal Fbrtn is not often met with in passive cerebral
c J 'V.on^ and, when it is, the delirium, so far from being of a furious
t}l- , I- I >w. The patient mutters to himself incoherently, and exhibits

42 DISEASES OF THE BRAIN.

great muscular restlessness, but never attempts to do violence to him-
self or others. Coma often occurs as a sequence.

f. The Aphasic Form, — Aphasia without other complication is not
often met with as a consequence of passive cerebral congestion. Two
instances only have come under my notice, and in both the development
was much slower than is usually the case in the active form of the affec-
tion. In both of these there was disease of the right side of the heart|
manifested by mitral and tricuspid regurgitation, jugular pulsation,
great fullness of the veins of the neck and face, and ascites and general
anasarca. The loss of the idea of language was complete in both cases,
and persisted for about forty-eight hours. There was no paralysis^
stupor, or convulsion, and but slight pain. The ophthalmoscope re-
vealed the existence of great turgescence of the retinal veins, with ve-
nous pulsation.

Causes. — The causes of cerebral congestion are: of the active form,
those influences which are capable of increasing the quantity of arterial
blood in the brain : of the passive, those which produce a similar effect
upon the amount of venous blood circulating in the vessels within the
craniimi. The causes of the first category induce activity of circulation,
those of the second torpidity.

The causes of active cerebral congestion may either, by their grad-
ual operation, initiate the premonitory stage, or they may suddenly
induce the development of this stage into one or other of the varieties
already described as constituting the second stage. Among them is
temperature either very high or very low. Thus, the disease is more
frequent in hot climates than in those of more temperate character, and
in the summer months than in the spring or autumn. It is, however,
more common in very cold than in warm weather. Thus Andral, of
one hundred and fourteen cases, found that twenty-six occurred in sum-
mer and fifty in winter. My own experience is to the same effect, as
will be seen from the following table, which embraces the cases in my
private practice in the city of New York during a period of five years,
beginning January, 1865, and ending December, 1870 :

January 66 July ' 68

February 64 August W

March 60 September 27

April 89 October 81

May 42 November 52

June. 87 December 72

Total «22

An examination of this table shows that one hundred and ten cases
occurred in the autumn months, one hundred and thirty-one in the
spring, one himdred and seventy-nine in summer, and two hundred and
two in winter. All my subsequent experience is to the same effect.

CEREBRAL CONGESTION.

Passive c+rebral congestion is very much more frequent in cold than
Id warm weather.

The direct rays of the sun are capable of producing sudden attacks
(iniio)atio), of which congestion is a prominent feature^ but which re-
quirr separate consideration : and it is not uncommon for artisans,
whdae boAcb are exposed to heat from furnaces^ to suffer in a similar
atiiaer.

Some authors contend that certain winds increase the liability to

fbfttl congestion. Louret, quoted by Mosmant,' could attribute an
io of cerebral congestion, which appeared at Charenton, to noth-
ing bot a long-continued wind from the northwest. The supposition
tli^ atmospheric electricity is a causative influence rests upon nothing
bat hypothesis.

Unliealthy situations, such as those subject to the influence of ma-
laria and to noxious emanations of any kind^ and which are not well
rentilatedy also predispose to attacks of cerebral congestion.

ingestion of a large quantity of food into the stomach may oc-

passive congestion, by the pressure which the distended organ

upon the large veins of the abdomen. Rapid eating, even

tboQi^fa the quantity of food be moderate, may cause the active form of

Iba affection by some influence exerted through the sympathetic system.

Sudden and violent physical exertion, especially if made in the
•looping posture, is very liable to induce cerebral congestion, Child-
biitb is an instance in point, and I have known several cases to he
eatisad by severe straintng in the water-closet. The constipation of the
boweb rendering such efforts at defecation necessary, is itself produc*
tiro of the disease.

A dependent position of the head and constriction of the neck from
Am divas are also, by impeding the return of blood from the head, Hablo
ta tndurr congestion of the passive form.

Certain articles uf food and medicine, such as spices, alcoholic liquors,
opium, belladonna, quinine, etc., act either bj augmenting the power
of the heart) or by their effect on the sympathetic, paralyzing the vaso-
motor nerves, and thus increasing the calibre of the cerebral blood-ves-
•ela* In this connection, the influence of the nitrite of amyl, when in-
baled to increase the quantity of blood in the brain, may be cited as
an iaatance of tliis latter power.

Tiaiiors in the neck, or in other parts of the body where the return
of blood from the head may be impeded by their pressure, likewise cause
aoii|ga«tton« Other causes are to be found in certain diseases, as fevers
e( Tarious kinds, erysipelas, disorders of menstruation, the suppression
of h»aH>rrhagic or other discharges ; local aifections of the brain, as
eoiboltis, thrombosis, tubercle or apoplectic clots, and sympathetically
in the intestiiml canal, or irritation existing In other portions
1 ** EmaI siir ta Congiestioo C^r^bralc** PariB, ISSS.

H laria ae

H ventilat

44 DISEASES OF THE BRAIN.

of the system. Hypertrophy of the left side of the heart is a common
cause of active cerebral congestion ; and any affection of the right side
of this organ, tending to impede the return of the venous blood, is an
important factor in giving rise to the passive form of the affection
under notice.

But the most influential and common causes of cerebral hyperaemia,
and eventually of congestion, are to be found in long-continued intel-
lectual exertion, mental anxiety, or sudden, violent, or prolonged emo-
tional disturbance. It is from the action of such factors that the pre-
monitory symptoms are generally induced, though they may, especiaUy
those embraced in the last-named category, immediately develop a fully-
formed attack. The fact that cerebral exercise increases the amount of
blood in the head is made evident to all of us at times, by the disten-
tion of the superficial vessels, the suffusion of the eyes, the heat and
pain which we feel when we have overtasked our brains. Cerebral ac-
tion is always attended with hypera^mia, just as is the activity of the
liver, the kidneys, or other organs. Active cerebral congestion is thus
induced, and is, within certain limits, perfectly normal. But these limits
are liable to be exceeded — and, in this active period of the world's hisr
tory, often are — and then the condition described as the first stage of
congestion is established. The vessels, from continued overdistention,
lose their contractility, just as does the India-rubber band, used to keep
a bundle of letters together, when the package is too large, or it has
been kept stretched for a long time. An additional disturbing force,
heat, cold, an overloaded stomach, increased mental labor, emotional
excitement, or any of the causes mentioned, may suddenly evolve a
fully-developed paroxysm.

Emotion acts in a similar manner, though, as has been said, often
with more suddenness. The emotions of shame, of anger, and others,
cause the face to become red from dilatation of the blood-vessels, and a
like effect \s produced in the vessels within the craniiun. If the emo-
tion is very strong or lasting, a correspondingly-increased hyperasmia
results.

There are certain circumstances which render the action of the oauBes
specified more effectual or powerful. These are inherent in the indi-
vidual, and may be classed as predisposing causes. Among them are
sex, the disease being more common in males ; age, it being more fre-
quently mot with in middle-aged or old persons ; hereditary influence ;
hypertrophy of the left ventricle of the heart, by which the flow of
blood to the head is directly increased ; dilatation of the right ventricle,
by which its power is diminished, and the return of blood from the head
impeded j insufficiency of the aunculo- ventricular valves, or constriction
at the auricular or ventricular orifices on the same side, by which a
similar result is produced, and perhaps, though this point is by no
means established, shortness of the neck.

CEREBRAL GONGESTiaN.

Diagnosis, — ^Cerc^bral congestion may be confounded with cerebral

lorrhage, meningeal haemorrhage, embolbm, thrombosis, softening,

ffpOepsy^ urixutf^mia, stomachal vertigo, auditory vertigo, and with the

rcry oppcHiLte condition, cerebral anfemia. From each of these affec-

lions it is, however, distinguished by well-marked characteristics*

The premonitory symptoms are not liable to be mistaken for cere-
bfml hi^morriiage, but this error may be made as regards the second
stage. The apoplectic form is, however, distinguished from apoplexy
dtifi to e^ctruvasation, by the f^et that in it the loss of intelligence is
mrely complete, and that, when it is so, the mind is dormant but for a
f^w moments ; that sensibility and the power of motion are never alto^
girlher abolished ; that coma, when present, is rarely profound ; that
tlie paralysis, when it exists, b seldom limited to one side of the body ;
by the general absence of stertor, and puffing of the lips and cheeks in

> breathing ; and by the short duration of the symptoms.
FVom meningeal hiemorrhage it is discrimiuated by the comparative
■rililQcsas of the symptoms, and by the fact that they do not progrea-
KlJy augment in severity or intermit in violence.
Cerebral congestion and embolism present some features in com-
moD, apd it is therefore occasionally difliciilt to distinguish them. In
Uki formrr, however, the pulse is slow and the respiration regular and
deep ; in the latter, the pulse is more rapid, is often irregular, as is also
th» raapiraitioD ; in the fonner, there is increased heat of the head ; in
tiM lalieri the temperature of this part of the body is unchanged : in
ion the symptoms are transient, in embolism they are
.in the former there is often a distinct premonitory stage;
in tl>e latter, the attack always takes place without a moment^s wam-
iagf. Id the former, though tliere may be cardiac difficulties, they are
^ diffmiDi from those predisposing to embolism, which are consecutive
^B to <Hiilf>>corditis — ^generally rheumatic — and which implicate the semi-
^" lutmr or mitral valves, and in the fact that recovery from an attack of
oerebml congestion is generally complete, which is rarely the case in
mmh6B§au

From thrombosis cerebral congestion is diagnosticated by the cir-
cumMtmMUiem that in the former the progress of the disease is alow, that
ibete ta usnally well-marked paralysis from the beginning ; that the phe-
IfcOinieilft indicating mental disturbance are more strongly pronounced ;
thtki the articulation and memory for words are more permanently af-
^ leeled ; and, notwithstanding occasional remissions, by the persistency
^m mod gndual advance of the symptoms.

V Iti aoftening there are often a sudden loss of consciousness, persistent

V heoiiplegia^ and death in a few days. Again, tliere is delirium without
pumijaia or convulsions, and in other cases there is a gradual accession
of Ibe aympioms. This latter is the only form liable to bo mistaken for

congestion. It is attended with headache, feebleness of intel

46 DISEASES OF THE BRAIN.

lect, and a gradually-advancing paralysis generally, beginning in one of
the lower extremities, and extending to the whole of one side of the
body. The speech is always seriously impaired, and the mental dis-
order is of a far graver character. than that due to cerebral congestion.
The gradual advance of the affection to a fatal termination is also a
characteristic circumstance.

With urincemia cerebral congestion may be confounded, if only the
more obvious head-symptoms be taken into consideration. The history
of the case and full inquiry will always, however, enable the proper dis-
crimination to be made. Thus, in urinsemia the existence of kidney-
disease, as evidenced by a chemical and microscopical examination of
the urine, the anasarca of the face or limbs, and the repeated attacks of
convulsions and coma, will be sufficient diagnostic marks.

From epilepsy cerebral congestion is distinguished by the fact that
the former is not preceded by the group of symptoms constituting the
first stage of congestion ; that the congestion of the vessels of the face
and neck is preceded by. a death-like paleness ; that an aura is often
present; that there may be a peculiar cry; that the patient does not
stagger and fall slowly to the ground, but drops as if knocked down by
a severe blow; and that the tongue is frequently bitten. The reverse
is the case as regards all these phenomena in cerebral congestion. Nev-
ertheless, so accurate and experienced an observer as Trousseau, in his
clinical lecture on Apoplectiform Cerebral Congestion in its Eelations
to Epilepsy and JSclampsia,^ confounds the two conditions. Trous-
seau's views on this subject do not, however, appear to be accepted by
any large number of medical authorities. Epileptic vertigo is, as will be
shown at a proper place, a very different affection from any form of
cerebral congestion, and is not likely to be confounded with it. Epi-
leptic mania has, likewise, very few points in common with the disease
under consideration.

In stomachal vertigo the attacks of dizziness are often severe, but
they are clearly associated with gastric derangement, and only occur
I while the stomach is digesting its contents. Other sjrmptoms of dys-

' pepsia will also be noticed, while the mental and physical disturbances,

I which constitute so prominent a feature of cerebral congestion, are ab-

I sent. The distinction, however, is not always made.

i In auditory vertigo, or M6ni6re's disease, the dizziness is acoompa-

i nied with aural troubles, such as deafness and tinnitus, the face is pale,

"' and there is almost invariably vomiting, or at least intense nausea.

' Moreover, when there is loss of consciousness, the premonitory symp-

! toms are not such as precede the second stage of cerebral congestion,

: but are connected with the function of audition.

i . From cerebral ana?mia, the first stage of congestion is frequently not

clearly distinguished, and I have seen several cases in which patients
" "Cliniqnc M6dicale,*' tome ii., p. 66. Also Bazire's Translation, London, 1860, p. 19.

CEREBRAL CONGESTION,

''\ ration i

■ the bas

been treated for the one condition when the other was indubitably
pmeot* In both there are headache, sense of constriction, vertigo,
ootaes in the ears, numbness, mental confusionj loss of memory, inapti-
tude for labor of any kind, and at times loss of consciousness. But in
anapmia the face is not flushed, the carotid and temporal arteries do not
throb with violence; the pulse is quick, feeble, and irregular, the respi-
ration is hurried, the pupils are dilated, there are bellows-murmurs at
the base of the heart and in the veins of the neck, and the general as*
the patient is not of that rugge<l appearance so generally asso-
with cerebral congestion. In the syncope of cerebral anaemia the
paleness of the face, coldness of the skin, and feeblene^ of the heart's
action, will serve to draw the line between it and the apoplectic fonn of
eongestioa* The ophthalmoscope will at ail stages prove of great value
in the diagnosis.

Prognosis, — The prognosis is matenally modified, according to the
stage of the disease present when the patient is seen^ and tlie form of
attack from which ho may be suffering. Active cerebral congestion is
a itioro favorable typo than the passive. If the affection has not gone
bejood tho first stage, a fortunate issue may safely be predicted ander
Una tiae of suitable medical treatment; but, if, through neglect or im»
proper treatment, or indiscretion on the part of the patient, the disease
becomes fully developed, the prognosis is much more grave. I havo
never known a death to take place in any patient from this disease dur-
ing tho premonitory stage. The apoplectic and sojKjrifio forms are the
RsasI grave, and the prognosis is rendered more unfavorable with each
altaric. The ejiileptto form is ordinarily not dangerous to life, nor is the
paialjrtifs, mamacal, or the aphasie, except in old persons. Occasion*
aOj^ hawever, even in young and robust patients, death ensues during
tlm paroxysms of these forms.

The liability to secondary lesions, such as softening, cerebritis, htem-
oniiagt*, aneurisms, general paralysis, etc., must be taken into account
when forming a prognosis. The more frequent the paroxysms of any
fdnn, the greater the risk of some such finality.

The habits of the patient are also important elements m forming an
0pik]iioci in regard to the ultimate result. If these are bad, and are per-
iled in, the prcjbability is that no treatment will be of much avail in
prvvenling a recurrence. Moreover, by such a condition of the brain
If tha excessive use of alcohol, inordinate mental exertion, or continual
amoikicial excitement induces, the chance of escaping some secondary
norbid proeesa is very much lessened-

Of the one hundred and seven fully-developed cases which have been
isoder roy obser\ation during the past eight years, there were eighteen
(leatiia; aeven from the apoplectic form, all after repeated attacks; three
frooa tbe maniacal, one of which was that of a young man about thirty
yaaie of age; and seven from secondiiry lesions. Of these latter, four

48 DISEASES OF THE BRAIN.

were from softening, one from oerebritis, one from hsemorrhage, and
one from general paralysis.

Morbid Anatomy. — ^There are certain appearances seen in the brains
of those who have died of cerebral congestion which are characteristic,
although it must be confessed that some or all of them are occasionaUy
absent. These are:

An increased size of the capillaries and large blood-vessels, both of
the brain and the pia mater. It thus happens that, when a section of
the brain is made, the red points ordinarily seen are larger and more
numerous than usual, and that the pia mater presents in spots, or
throughout its extent, a red or rose-colored appearance.

The white matter of the brain is increased in consistence and density,
and the gray matter is red, or even violet in hue.

There is sometimes a large quantity of subarachnoidean effusion, the
ventricles may contain an excessive amount of fluid, and the choroid
plexuses are often enlarged.

If there have been repeated attacks of cerebral congestion, it is not
unusual to find, by microscopical examination, little granules of haematin
in contact with the blood-vessels. The same means of exploration shows
the minuter capillaries to be more than naturally tortuous, and to have
little aneurismal swellings. These may or may not involve the whole
circumference of the vessel. Their presence and import were first
pointed out by Laborde.'

On making a transverse section of the hemisphere, a cribriform ap-
pearance is seen, if the patient has repeatedly suffered from attacks of
cerebral congestion, and especially if he be advanced in years. This is
due to the presence of numerous little holes with sharply-defined mar-
gins. The brain-tissue bounding these is generally without material
change, either in color or consistence. This condition, called by Du-
rand-Fardel,* to whom the credit of first describing it is usually given,
" r^tat cribl^," is supposed to be due to the fact that the vessels have
been so distended during life as to press with increased force upon the
perivascular tissue, and that, shrinking after death, they no longer fill
their former space, which remains empty. Calmeil* was the first to
notice this condition. He has very often found, in maniacs, the white
substance rendered cribriform by vessels distended with blood, some-
times empty, but always greatly dilated. This state, although fre-
quently met with in congestion, is not uncommon in other pathological
conditions, such as the several forms of softening, of which, however,
congestion is often the first stage.

1 **La ramollissement et congestion da cerveau principalement oonBid^r^ ches de
rieiUard/' Paris, 1866.

* " Traits pratique des maladies des yieillards.^* Paris, 1864, and deuxi^me ^(fitiaii,
1878.

' *'Dc la paralysie considerce chez les ali^n^s,** etc. Pans, 1826.

CEREBRAL CONOESTlOJf.

Dtiraud'Fiirdt^l * culls attention to the fact that, on making' sections
of the medullary substance of the cerebrum, it is not unconunon to find
isi Ottacs of congestioci rose-colored patches scattered throughout its
sabBtance. On examining these with a lens, they are seen to consist of
t large number of delicate vessels partially injected. I have never wit-
OMied this appearance, except in one iostance, nor is it noticed by au-
ihoTB on the subject generally.

11 Uic congestion hiis been severe or long continued, the convolutions
IBmy be to a considerable extent obliterated by the compression of the
bmin against the internal ^vall of the cranium. At the same time, the
membranes of the brain are rendered dry and viscous from the pressure
lo wUcli they have been subjected*

Id passive congestion the sinuses of the dura mater are the chief
Mcmla of vascular turgescence; the veins generally are distended, and
ibetie 19 ordinarily a greater amount of serous eifnsion in the subarach*
ooid wpmce than iii the active variety of the disease.

PEtbology. — It is almost useless at this day to discuss the question
of the possibility of the quantity of blood in the brain being subject to
variation. Still, it may be interesting to recaJl briefly the facta which
the affirmative in the matter,
he cases of infants, in whom the anterior fontanelle is stiU open^
tic scalp is seen to be elevated above the level of the skull when the
hemd is dependent, and depressed when the head is elevated.

The same fact is observed in persons who have sufferml injury of the
akyll, involving the loss of a portion of its stibstanoe. During strong
emotional excitement, or the action of any cause capable of increasing
the foroe of the circulation, the sc4ilp is elevated. From the action of
tl- ^ it is depressed^ Both in infants and in persons who

injuries such as those cit^d, the scalp is seen to be de-
prtiflBod during sleep, and to rise as soon as the individual awakes.

A dependent position of the head causes a sensation of fullness, or
even pain, and blood may flow from the nostrils. The eyes are observed
ta b*! ** bloodshot," and the countenance indicates congestion. A tu-
Rkur, a ligature, or any other cause capable of exerting pressure on the
janular reins, will produce like effects. Ophthalmoscopic examination
uodor aticb circumstances shows the veins of the retina to be enlarged,
todieaiaig that an obstruction exists to the return of blood through the
fiiMir^ and veins within the cranium. Post*mortem examination of
ptnotia dying, who, during life, have snflfered interruption to the per-
fect relnm of bhiod from the head, reveals the existence of intracranial
eoagtcsiiocu Animals, subjected to experiments calculated to act in the
nimicr stated, are after de«ith found to have congested brains*

In animals bled to death the brain is found anjemio to an extreme

» OfK eii., Paris, 1878, p. 21,

50 DISEASES OF THE BRAIN.

Direct experiment still more positively establishes the fact under
consideration. If a portion of the skull x)f an animal be removed, and
the aperture be then securely closed with a watch-glass, the vessels will
be seen to enlarge and contract according to the cause brought into
action, and the brain will be correspondingly elevated or depressed.

By means of an instrument, devised, independently of each other, by
Dr. S. Weir Mitchell and myself, the degree of pressure within the cra-
nium can be accurately measured. It is thus seen that the quantity of
blood circulating in the brain undergoes material variation,*

The anatomical arrangement of the blood-vessels of the cerebral tis-
sue is such as to admit of an enlargement of their calibre without neces-
sarily subjecting the perivascular substance to pressure. Robin " dis-
covered the existence of sheaths around these vessels, and his observa-
tions were subsequently confirmed by His," who ascertained that the
same arrangement exists in the spinal cord. According to His, " Fine
transverse sections of a hardened brain, having its vessels injected or
otherwise, show that all the blood-vessels, arteries, veins, and even
capillaries, are surrounded by a clear space, broadest in the case of the
larger vessels, but in all cases quite sharply defined externally. In
transverse sections, the vessels are seen to be surrounded by a ring-like
space, and in parallel sections the space is seen on each side of the
trunk of the vessel, and follows it in all its ramifications."

These perivascular canals are lined by a hyaline membrane, and are
capable of being injected, and, in cases of chronic congestion, may be-
come permanently enlarged, so as to cause the appearance referred to
under the heading of morbid anatomy.

The pathology of the subject receives further elucidation from a con-
sideration of the causes capable of giving rise to cerebral congestion,
and which have been already mentioned in detail.

Treatment. — Recollecting the two grand fonns of cerebral conges-
tion, the principles which should guide us in treatment will be clearly
apparent. In the active type of the disease, the force of the cerebral
circulation and the quantity of blood in the blood-vessels of the brain
are to be lessened; in the passive variety, the force of the circulation
is to be increased, and at the same time the accumulation of blood in
the veins to be diminished. In the active form of this affection, the
abstraction of blood from the arm was formerly very generally praotiaed,
but is now rarely performed. I have never seen a case in which it was

^ For a more complete argument on the subject, and for a statement in detail of the
experiments of Mr. Durham and myself on this point, the reader is referred to the author's
monograph, " Sleep and its Derangements." Philadelphia : J. B. Lippincott k Co., 1870.
The cephalo-hseraometer referred to in the text is described in that work (Appendix), and
also in the introduction to this treatise.

■ Journal de laphytiologie de Vhomme et de8 animauz^ 1859, p. 627.

» "Zeitschrift fur Wissenschaftliche Zoologie," 18(55, B. xv., quoted in the Journal qf
AruUomy and Phytiology. Translation by J)r. Bastian. .

• •• » ••••

• • • • ••••••

•••• • •••••••

••• • •••••••

OSRBBIUI. OOJfGGSnON.

required. Local bleeding is more generally applicable, and a few cups
10 the nape of the neck wil! often afford marked relief. Leeches to the
temples arc also useful, though they are preferably applied just inside
iho nostrils, I have many times witnessed the most satisfactory results
imm a couple of leeches thus used, antl from accidental na8al*ha?mor-
rbage.

Cold is another very useful agent in the treatment. It may be ap-
plied to the nape of the neck, or directly to the craniara, either as very
0eld water or in the form of ice*

The advantages of position should also be brf>ught to bear. The
head should be kept elevated, especially dunng sleep, and no severe

cular exertion should be taken while stooping.

The clothing Bhould be kept loose about the neck. As dcrivativea,
m imiatard-pla.Hter applied to the epigastrium is often of service; and the
WKmp may be said of wanu or even hot water to the feet. Blisters I
mirlr employ, though I have occasionidly done so with advantage.

Tho constant galvanio current possesses the power of contracting
line ceivbral blood-vessels, when so used as to stimulate the sympatlietio
neff^Ou For this purpose, one pole should be placed over this nerve in
Ibe neck; and the other on the back of the neck, as low down as the
Beirentb cervical vertebra. The current from about fifteen Smee's cells
is »iifBcient, and it should not be allowed to act for more than two
mhmtes* If extreme vertigo be produced, the number of cells should
be l«WNnjed, This property of the primary current was first pointed out
hj D<*mard, Waller, and Budge, but its demonstration by the ophthal-
noeoope waa first made by m>ngelf.* Observation with this instrument,
wliQe the current is acting, shows that the vessels of the retina con-
ttwct, aod henoe there can be no doubt that the result is produced
upon those of the brain, A similar effect is caused by passing the
rurrent directly through the brain, the poles being applied to the
mastoid [iroc*esses, A slight feeling of vertigo follows both when the
csreuit iji dosed and opened. The good effects of this practice are well
marked, a few applications being often suflicient to abolish the vertigo
and trnpleajuutt feelings in the head, and to restore mental and physical
•cdTity,

Of iaieraal remedies the number is not large, and those which it ia
idvMblo to employ are generally effectual, with or without tho external
TfHimrtTi m^'ntioned, in entirely relieving the patient,

Fimt among these must be placed the bromide of potassium* Sev-

S99 a iUi*tnoir eutttk^l ^'5pLQAl Irritation/* roAtl before the Modicut Society of did
r of Ki'w York, JiQiLtry 17, 1870, luid publUlied in the Journitl of P»>n'hol4i^ieal
r ibr ApHl of tlie t»ume jear. Also anotbt-r, ^* On wome of tiie EfftHrt-j of Exc«afllT«
I Ei*?rtiw," in ih^ Bcllcrne and Charitj Hofpital Reports for 1870. In both
Ihat |>t|>ai*i >^'l (<^ i^y tiTttireg to the dM® of tbe Hellcvae HosptUJ Hedical OoUcge, I
IfBTr aiaile liiiCSnH iti.nfiMn of thin fact»

52 DISEASES OF THE BRAIN.

eral years ago I pointed out the value of this medicine, and explained
the ratiomde of its action. As others have since claimed the discovery
as their own, I hope I may be excused for quoting the following pas-
sage from a memoir upon an analogous subject,* in which the action
of the bromide is clearly indicated:

" Bromide of potassium can almost always be used with advantage
to diminish the amount of blood in the brain, and to allay any excite-
ment of the nervous system that may be present in the sthenic form of
insomnia. That the first -named of these effects follows its use, I have
recently ascertained by experiments upon living animals, the details of
which will be given hereafter. Suffice it now to say that I have
administered it to dogs whose brains have been exposed to view by
trephining the skull, and that I have invariably found it to lessen the
quantity of blood circulating within the cranium, and to produce a
shrinking of the brain from this cause. Moreover, we have only to
observe its effects upon the human subject, to be convinced that this
is one of the most important results of its employment. The flushed
face, the throbbing of the carotids and temporals, the suffusion of the
eyes, the feeling of fullness in the head, all disappear as if by magic
under its use. It may be given in doses of from ten to thirty grains,
the latter quantity being seldom required, but may be taken with
perfect safety in severe cases."

Since then, experiments with the cephalo-haimometer and ophthal-
moscope have abundantly confirmed these views, and more extensive
experience in the treatment of cerebral congestion has placed the
matter beyond the possibility of a doubt. Other observers have also
confirmed the opinions here expressed.

The prescription which I usually employ consists of bromide of
potassium, ^ j ; water, | iv ; of this a teaspoonful is taken three times
a day in a little water. Occasionally the bromide is increased to J W8>
and sometimes a saturated solution — which contains grs. xxx to 3 j —
is used. I continue the medicine till drowsiness, a slight feeling of
weakness in the legs, and contraction of the blood-vessels of the retina
— detected by the ophthalmoscope — are produced. The more promi-
nent head-symptoms generally disappear in four or five days, and the
results above-mentioned ensue in about ten days.

Latterly I have used the bromide of sodium in corres}>onding doses
instead of the bromide of potassium. It is more pleasant to the taste,
and does not cause so much constitutional disturbance as sometimes
follows the administration of the bromide of potassium in large doses.
The bromide of calcium is also well adapted to the treatment of cases
of active cerebral congestion, and has the advantage over the other
bromides of acting more promptly.

As is well known, ergot possesses the property of constricting the
* "On Sleep and Insomnia.'^ New York Medical Journal, June, 1866, p. 208.

CEBEBRAL CONGESTIOir.

orgamc muscular fibrt\ This property has for several years past
its suocessful application to the treatment of those diseases of the spinal
cofd in which it is desirable to lessen the amount of blood in its ves-
sels* It is only lately, however, that this agent has been employed in
sitnilar affections of the brain. From my own experience, as well as
from a consideration of the investigations of others, I am entirely satis-
fi«?d that ergot does contract the cerebral vessels, and hence that it di-
isiliklshes the quantity of intracranial blood* Among the first, if not
ibo rery first, to call attention to this property was Dr. Charles Ald-
ridge,* who noticed that after the administration of a full dose he found
tl to cause '* contraction of the arteries of the retina and loss of the
ospQlarT tint of the disk.** My own observations are entirely in accord
with these results. I have repeatedly found a single dose of two
dmrhms of the fluid extract produce a decided diminution in the calibre
of the retinal arteries, and a marked pallor of the disk.

In addition^ some recent experiments which I have performed upon
dogs, in which the ergot was administered hypodermically in doses of
twom one to three drachms of the fluid extract, after the animals had
beeii trephined and the cephalo-ba^mometer inserted into the opening in
fke skull, showed from the falling in the tub^ that the intra-cratual
pKssars was notably lessened.

Applying these facts clinically, it is found that ergot is of very
^reai %'slu6 in the treatment of active cerebral congestion in all its

LiOfm% hut es]>ecially in the first or hypememic stage. I am in the habit
«l ginng drachnwloses of the Hiiid extract three times a day, in coiu-
blutioa with some one of the bromides. An excellent formula is sodii
liroiiiidi, I j; ergots' ext. fluidi, i iv. M. ft, sol Dose, a teaspoonful
thrN! tttnris a day.
L Or the ergot may be given alone either in the form of the fluid
BKtracI^ or of the ergx>tin of Beaujon, which is simply a solid extract.
This latter is made into pills of from three to five, or even ten grains

Iotteh^ one of which should bo administered three times a day.
In the Ursi or hypeni?mio stage, and especially where the pain in the
hettil has been a prominent feature, I have frequently seen prompt relief
tif tile eerebral distress, from the administration of ten or fifteen grains
of paullinia* The fluid extract, a more eligible preparation than the
powfl* ^M> given in doses of a half to a full teaspoonfuL

In tion with these remedies I very generally employ the oxide

of ov^f which experience has taught me is a i>owerful agent in relieving
€tf«bnd ©ongesti* in^ and giving tone to the nervous system. It should
b^giTen in dosrs of gr8» ij, three times a dny, either in the form of a
pm or powder, and to a%*oid any nausea should be taken after meals.
At the end of about ten days it will generally be found that under

^ '* Wc«t Riding Lanalic Asylum RrporU/* vol U p- '^It LondoDt 1871 ; also vol ilL,

54 DISEASES OF THE BRAIN.

this treatment all symptoms of congestion — subjective and objective-
have disappeared, leaving a little debility and mental depression. I
then becomes expedient to give tonics and restoratives, and those whioi
have a special action on the nervous system are to be preferrec
Among them, strychnia, phosphorus, and cod-liver oil, stand first.

Strychnia may be advantageously administered in conjunction wit
iron and quinine dissolved in dilute phosphoric acid, as in the following
formula: Strychniae sul., gr. j ; ferri pyrophosphatis, quinias sul., aa 3 j
acid, phosp. dil., zingiberis syrupi, aa, 3 ij. M. ft. mist. Dose, a tes
spoonful three times a day in a little water. I prefer this extempc
raneous prescription to any of the syrups or elixirs with like ingredi
ents. If for any reason the iron and quinine are not indicated, th
strychnia can be given alone with the dilute phosphoric acid.

Phosphorus almost always acts well in such cases as those unde
consideration. It may be given in the form of the phosphorated oi
as in the following formula: g. Olei phosphorat., 3 ss ; muciL acacia
3 j ; olei bergamii, gtt. xl. M. ft. emulsion. Dose, gtt. xv. three time
a day.

A very elegant preparation of phosphorus is the phosphide of 2in<
The chemical formula of this substance is Zn^ P, and consequently
grain represents a little more than one-seventh of a grain of phosphorui
The proper dose, therefore, is about the tenth of a grain. I usuall
prescribe it in cerebral congestion, according to the following pn
scription : ^ . Zinci phosphidi, grs. iij ; rosar. conserv., q. s. M. ft. i
pil. no. xxx. Dose, one three times a day. Instead of the conserve c
roses, grs. x of the extract of nux-vomica may be substituted if stryol
nia is not being administered in some other form.

Another very useful form for administering phosphorus is th
phosphorated resin, which contains four per cent, of phosphorus, thoi
oughly rubbed up with ninety-six per cent, of resin. This is made int
pills with conserve of roses, or some other excipient. The dose is abov
half a grain, containing the one-fiftieth of a grain of phosphorus.

Latterly I have made much use of arsenious acid in cerebral coi
gestion, especially in cases which have been the result of menti
exertion or anxiety. Its action is certainly preferable to that c
Fowler's solution. It should be given in doses of about the fiftieth of
grain, and after eating, and should be continued for several weelu
Lisle * administers it in the quantity of from a fourth to the third of
grain daily, and there is no doubt that it may be given to this exten
without danger. I have never, however, unless there was manifee
insanity, used it in these doses.

Such is the treatment I have found to be most advantageous i
active cerebral congestion, and I rarely have occasion to supplement i

* " Du traitemcnt de la congestion c^rebrale et de la folie avec congestion et ha
lucinations par Tacide ares^nieux.** Paris, 1871.

CEBEBRAL CON'OESTIOK

With other measures, unless some special indication is to be fulfilled.
• Thus, if the bowels are constipated, a mild purgative may be given, or
preferably an enema of warm water or olive oil ; or, if the urine is
•canty and high-colored, saline diuretics are useful*

In the passive form of the disease it is sometimes advisable to
give stimulants, which may be done from the first in conjunction with
the bromide of potassium, sodium, or calcium, with ergot. Alcohol in
001116 form is to be preferred when it is well borne, though carbonate of
ammonia is sometimes a useful substitute. In several cases of passive
cerebral congestion in old people, and in one notable instance occurring
in the person of a very prominent elderly gentleman of this city, I
derived the most satisfactory results from sulphuric ether inhaled from
a handkerchief to the extent of a teaspoonful, several times a day.
The pain, constriction, vertigo, numbness, wakefulness, and inability to
exert the mind, were lessened with every dose, and finally entirely disap-
peax^d. Ether may likewise be given by the stomach — ^gtt. xv aeveral
times daily — in case the inhalation is contraindicated from any cause.

Of course, any influence capable of interfering w^ith the *due return
of blood from the head should be counteracted at once.

In the two cases of aphasic cerebral congestion of the passive formj
to which reference has been made, I derived the most signal benefit
from the use of infusion of digitalis in tablespoonfuWoses administered
erery four hours.

Hygieoic treatment should in both types of the disease be persist-
ently carried out. The food should be nutritious, digestible, and ample,
though not excessive, in quantity. Alcohol and tobacco, if used habit-
uaBy by the patient, should bo restricted to moderate limits; I liave
oever seen the latter do harm unless used to excess. Tea and coflfce
may safely be left to the patient's own inclinations and experience, I
believe more harm is done by suddenly breaking off a hatit, even though
H be somewhat injurious, than by tolerating it within due bounds. Ex-
c^rctse in the open air^ — walking, horseback -riding, or driving — is always
T The same cannot be said of gymnastic contortions, which,
them worse, are usually performed in hot rooms. Bathing
daily and subsequent friction with a tape towel are exceedingly useful
in ili5t«!rmining blood to the surface of the body. Tlie Turkish bath
cannot be too highly commended.

But, above all, those persons who have brought on the disorder by
inordinate mental exertion or anxiety, must consent to use their brains
in a rational manner if they wish to recover or to avoid future attacks.
T" ' 'd a warning, and, if they do not heed it, snouer or

L s, more difficult if not impossible of cure, will make

their appearance.

But it is not always the case that the most positive advice on this

it is followed. Men who would readily see the impropriety of walk-

56 DISEASES OF THE BRAIN.

ing three or four miles while suffering with an inflamed knee-joint, do
not hesitate to exert a disordered brain to the extreme limit of its
2>ower. It is impossible that the action of a brain thus affected can be
such as to evoke sound and healthy thoughts. It is not to be won-
dered at, therefore, that the subjects of cerebral congestion who insist
upon attending to their avocations and on concocting schemes for obr
taining wealth or fame, should perpetrate acts which result in the loss
of fortune, and the acquisition of a reputation far different from that
sought. •

The cause of cerebral congestion, whatever it be, must, if practicable,
be removed, and it must continue removed.

CHAPTER II.

CEREBRAL ANEMIA,

In cerebral ansemia the quantity of blood in the brain is either re-
duced below the normal standard, or the quality of the circulating fluid
is impoverished. The first-named condition is due either to direct loss
of blood, to deficient action of the heart, to impaired nutrition, or to
some cause preventing the duo access of blood to the brain ; the second
to disease of some organ concerned in ha^matosis or to a general ca-
chexia.

The two states very often coexist, and they may properly be consid-
ered together.

Symptoms. — In cerebral anosmia, suddenly induced from profuse
haemorrhage, the most prominent symptom is syncope. Vertigo is gen-
erally an attendant, and there arc paleness of the features and coldness
of the extremities. The pulse is frequent, thread-like, and weak. The
respiration is feeble and accelerated.

But, when the accession is more gradual, headache is very generally
present. It may be, and usually is, confined to a limited portion of the
head, sometimes to a spot not larger than the point of the finger. A
feeling of constriction, especially across the brows, is complained of,
and the vertigo, notably increased on rising from the recumbent post-
ure, is as troublesome a feature as in the worst attacks of cerebral con-
gestion. There is ringing in the ears, and loud noises are not only
painful but are exceedingly irritating to the nervous system. The
pupils are largely dilated, and are sluggish, contracting slowly and but
little on exposure to a strong light. These phenomena may be re-
stricted to one eye, a circumstance which generally occasions needless
alarm on the part of the patient. The retinae are extremely sensitive,
and hence ophthalmoscopic examination is painful. When employed.

CEREBRAL ANEMIA.

in 111

ilntiiilii at tbe fundus of the eye are seen to be snmU and straight,

llhe ehoroid h paler than is normal*

Owing to paresis of the ocular muscles — a very common condition
in onset of cerebral anoemia — the attempt to use the eyes, as, for in-
stance, in reading, produces pain in them and ia the head. In many
easos the effort of three or four minutes causes very great uneasiness.

The complexion is pale, the lips almost colorless, or else redder than
in health. The skin is cold and clammy.

Nausea and vomiting are present in extreme cases, and convulsions
^^ joi an epileptic character may occur. In the rapidly-developed form of

I disease, caused by sudden and great loss of blood, they ai-e always
ptesent, and in the milder and more gradual variety they are oocasion-
ttDy aet'n. Feebleness of muscular power is always met with, and there
ftiay be general or partial paralysis, with tlie usual derangements of sen*
aibility indicative of aofesthesia, such as coldness^ formication, and ^'pins
and needles.**

Thr mind, of course, participates in the general disorder* In ex-

,lvifme cases, due to active hicmorrhage, the patient is completely iixscn-

Jeu III leas severe forms there may be all the gradations from low

cT at mental irritability, or a condition of intcDoctual laasi-

fi . ^ ^ T iig dementia,

Hallticmations and illusions are common in the slowly-developed
farms of cerebral amemitt, and may affect any one or all of the senses.
Tlioee of sight and hearing are, however, more prominent. In tlie case
of s young lady under my care, and whose only marked disorder was
that ttnilcr consideration, the hallucination that she saw a black man
wail almost constantly present. At tiroes she conversed with this im-
J^^Utary being, told him not to trouble her, that she no longer feared
^^ lilB^ etc She believed firmly in his presence, and hence -had a delusion.
^B In &D cases of cerebral anaemia there is more or less drowsiness, from

!■ ik0|M^^found svncope of the rapid form to the rather agreeable lani^u'^^r

^^^rBtOtit in slight cases. In instances of medium severity, the pati* nl
reality falls asleep in the sitting posture, but rcmimbency induces wake-
fitlnMA, from the fact that the quantity of blood in the brain ia thereby
•nddenly inereas<?d above the habitual standard, and a state of compara-
fire bjrperaemia is thus induced, I have, in another place,' called atten-
Btm to this form of insomnia, and adduced several cases. in iQustration,
Examination of tbe heart by auscultation reveals the existence of
WkmiMaunnure both systolic and diastolic, lli(»y are heard more
knafly at th^^ base of the heart. There are also very generally venous
murmunt, which arc heard most distinctly in the jugular veins, espo^
exally when the head is turned towanl the opposite side. Arterial nmr-
raori may also oeoasionally be perceived

» •cniDds are sometimes heard by the patient, and are then ex«
' ** Sloq> and it« Dcnuig^meots.^*

58 DISEASES OF THE BRAIN.

ceedingly annoying. I have had under my charge patients suffering
from cerebral anaemia, who constantly heard a soimd originating ap-
parently in the head, and which, as they described it, resembled that
caused by a large shell placed to the ear. That these murmurs are
anaemic, is shown by the fact that they disappear under appropriate
treatment.

Cerebral anaemia may be of such intensity and be so suddenly devel-
oped as to cause almost instant death. Many cases are on record, of
patients having died with symptoms of apoplexy, and in whom post-
mortem examination has shown the blood-vessels of the brain to be
empty, and the brain itself pale and exsanguined.

Paralysis of various forms may likewise result from this condition.
Sometimes there is hemiplegia, at others paraplegia, again a single
muscle or a group of muscles may be affected, and it may even happen
that a general state of paralysis may exist. I have frequently seen a
single muscle of the eyeball alone involved, and upon one occasion
witnessed the loss of muscular power confined to one side of the face
in the person of a lady whose brain was evidently very anaemic

Gintrac * cites the following interesting cases conununicated to him
by Dr. Hirigoyen :

"A young girl twenty years old, affected with amenorrhoea, con-
sulted a midwife, who bled her, attributing her trouble to cerebral pleth-
ora. She had hardly lost two hundred grammes of blood when hemi-
plegia supervened. Iron and tonics entirely dissipated this condition.

A young woman, twenty-five years old, was subject to a severe
epigastric pain, that had been several times relieved by bloodletting.
She was thin, pale, and nervous. Nevertheless, a vein was again opened,
but only about one hundred and fifty grammes of blood were taken.
Notwithstanding this prudence a syncope ensued, while the arm was
being tied up, and there were some convulsive movements. After two
or three minutes the patient recovered her senses, but was found to be
entirely hemiplegic on the left side, and to have some difficulty of
speech. Recourse was had to Hoffman's anodyne, valerian, and appro-
priate food, and at the end of thirty-six hours she was relieved."

A form of cerebral anaemia met with in young children is of great
importance, from the fact of its liability to be confounded with another
far more dangerous affection, almost its opposite. This was first clearly
described by Dr. Gooch,' although previously noticed by other ob-
servers. In children suffering from this affection, the symptoms, so far
as they are noticeable, are similar to those present in the amemia of
adults. The drowsiness is well marked, the head is cool, the pulse is

* " Traitd th6oriqiie et pratique des maladies de Tappareil nervcaux.*' Tome pre-
mier, Paris, 1809, p. 648.

• "On Some of the most Important Diseases peculiar to Women; with Other Papers."
New Sydenham Society Publication. London, 1859, p. 179.

CEREBRAL XHMKUT

k, the features are pinched, the pupils large and insensible
the fontaiielle, if still open, has the scalp covering it de-
planed* After death, the vessels of the brain are found to be almost
empi^f and the ventricles distended \i ith fluid. From its resemblanoe
in some respects to liydrocoplialus or tubercular meningitis, this afFec-
lion was called by Dr. Marshall Hall hjdrocephaloid. The distinction,
hciwcver, ia so well defined, that none but the most ignorant or super-
ficial obsen^ers would fail to recognize it.

Causes, — ILemorrhage or other exhausting discharge ranks first
among the causes of cerebral ann^mia, 1 have known several severe
oases induced by epist^xis, and one by the continued loss of blood from
leech-bitos, Hii'morrhoidal bleeding has also caused it in my experi-
ence. No influence of the kind is, however, more common than uterine
blecKling, such as occurs before, during, or after labor, from miscarriages
Slid abortions, especially if they are frequently repeated, and from ex-
oomve menstrual discharge.

Clironic dysentery and diarrhira, malarial and other fevers, the rheu-
oiatto, atrumous, and cancerous diatheses, diseases of the bones and
loints, and long-continued purulent discharges, are likewise causes of

bral ana'^mia,

I have several times seen the affection apparently caused by conges-
tion of iiit<?rnal organs. Nieraeyer, referring to this possibility, cites
tte fact that it may follow the use of Jounod's boot. At the present
tim*^, wltp-n thia appliance is variously modified and extended beyond its
I use by itinerant quacks, it is well to call special attention to

i»«..*uty. Several cases in point have come under my observation,
in on«?, a young lady suffering from epilepsy with cerebral anti.*mia,
I aaw in consultation with my friend Dr. J. Marion Sims, severe
puoxjama were induced by each a]>plication of the " exhauster." In
iKb case the operator placed the whole body, with the exception of the
in a vacuum. In another instance, exhaustion from the leg alone
ayncope every time the operation was performed.

Pnsasure upon or obliteration of the arteries supplying the brain is
T cause, A lady was formerly under my notice, in whom both
id arteries had be^n tied, for cirsoid aneurism of the scalp, by the
latii Dr, Kearney Rodgcrs and my friend Prof. W. H. Van Buren.
Wben I saw her, several years after the operation, there was well-
inarbed cerebral anccmia, the most striking symptoms of which were
fVftigoarii *neas. Tumors of various kinds may act in a similar

m&ner, -ss of the hearths action, such as results from fatty

dttgeneration, may also occasion cerebral amemia.

As we have seen, excessive mental exertion is a common cause of
oerobiml ooiig«stion. Strange as it may appear, I have had several cases
oC etfftfacal amrmia un<ler my care, in which the disease was clearly the
ftmih itt m like cause, and these were instanees in which the brain had

60 DISEASES OF THE BRAIN.

been overtasked to an extreme de^ee. A little reflection will, I think,
show that such cases are strictly in accordance with what takes place in
other parts of the body. Thus, we see the moderate use of a muscle or
set of muscles increase their size and strength. Inordinate exercise in-
duces hypertrophy, but, if the power of the muscles be still more se-
verely tried, atrophy results. One of the worst cases of progressive
muscular atrophy I ever saw occurred in the person of a ballet-dancer,
whose gastrocnemii muscles were the apparent starting-points of the
disease. Excessive cerebral action produces exhaustion, and exhaustion
causes aniemia, as surely as anosmia causes exhaustion.

The action of mental emotions is more obvious. We know that
some emotions increase the amount of blood in the brain. Others di-
minish it, and sometimes with such suddenness as to cause syncope.
Fear is one of these, and we have all seen the face become paler under
its influence.

Certain medicines are causes of cerebral anaemia, both by their ac-
tion on the vaso-motor nerves and in diminishing the power of the
heart. Tobacco, tartarized antimony, calomel, oxide of zinc, and the bro-
mides of potassium, sodium, calcium, and lithium, are among the chief of
these. I was the first to point out this influence of the bromides, and,
in a recently-published memoir,* have given several cases in illustration
of its action. The drowsiness, vertigo, nausea, fainting, weakness of
the muscular system, numbness, failure of memory, mental aberration,
pallor of the countenance, and anaemia of the retina, all go to show that
the quantity of blood in the brain is diminished. Recent investigations
not yet published have convinced me that the oxide of zinc acts in a
similar manner.

Insuflicient nutrition, either from deficient or improper food or dis-
ease of the digestive or assimilative organs, is a very common cause.
Through its influence not only is the absolute amount of blood lessened,
but its quality is deteriorated. The quantity sent to the brain is hence
diminished, and that which is supplied is lacking in its proper propor-
tion of red corpuscles. Many of the cases of cerebral anaemia occurring
in large cities originate from such influences, and likewise from the
vitiated air of narrow and crowded streets, from cold, and from depri-
vation of light.

Sudden cerebral anjcmia may be produced by the shock caused
by physical injuries, or even slight surgical operations unattended by
effusion of blood. Thus I have several times seen it follow immediately
on the passage of a urethral catheter or bougie for the first time.

* ** On Some of the EtFects of the Bromide of Potassium when administered in Large
Doses." (Quarterly Journal of Psychological Medicine^ January, 1869, p. 46. In this
paper I stated that one of the most constant phenomena was contraction of the pupils.
Very greatly increased experience has convinced me that this is an oecasional circiim*
stance, which occurs during the early period of administration only.

OEBEBRAL AN^UU.

*nie |3iissage of a galvanic current of too great a degree of intensity
tlifough the brain, may be productive of alarming sy tnptomB due to sud-
denly-ioduced cerebral anoemia. Upon one occasion I passed a current
frDDi ten cells transversely through the brain of a gentleman — the poles
being on the mastoid processes — with the effect of causing syncope,
exirejne nausea, a cold perspiration on the head and face, and such
feeble action of the heart as to cause me to apprehend the most serious
results* Placing the head in the dependent position, and causing him
to inhftlo the nitrite of amyl, soon restored him to cousclousnessi and
diasip&ted the other symptoms.

In another, somewhat siuiiliar though not so violent symptoms were
indnood by the passage of a current from only six cells. Cologne to
ibe nostrils, and a draught of strong whiskey, afforded prompt relief.

Tbese cases, as well as others within my knowledge or experience^
ffbow how sensitive some persons are to the |>rimary current, and indi-
cart* the care necessary m the use of this powerful agent.

An instance of extreme corebnil anemia, produced by excitation of
tlie pncumogastric nerve by a galvanic current of too great a degree of
mteinitj^ will presently be cited.

Diagnosis. — Tlio principal affection with whicli cerebral ana?mia is
Bible in be confounded, is cerebral congestion. Indeed, there is no
other which can be mistaken for it, if even ordinary perception and
ent be exercised.

From this it may be diagnosticated by the history of the case» and
m csroful inquiry into the etiology, by the fact that drowsiness, not
wmkirfnlness, is a prominent symptom; that the pupils are dilated tn-
«tei4 of being eoutmcted; that the pain is more apt to be fixed in a
finttled part of the head instead of being general; that it and the ver-
tigo are increased by the assumption of the erect position, and dimin*
iiiii»d by lyitig down; that the ophthalmoscope shows retinal aiurmia;
the face is pale and the skin cold; that the pulse is weak and fre-
\ and that ^>cli<>w^-mu^nu^^ are heard at the base of the lieart
aixl tn tho veins of the neck. The eETect of stimulants and tonics in
nitigalUig these s^Tuptoms, and the fact that they are increased by ex-
ntioiij and debilitating inlluencea, are also important points to be con-
sidered in forming a diagnosis. Attentive consideration of these dif-
fereottal pbe-nomena will prevent ii mistake which may be fatal to ihi^
|xaiii»nt.

PropiOifiis^ — Tlie prospect of recovery in eases of cerebral anieniia
depends mainly upon the removal of the cause, and the adoption of
mtmble treatment. In those cases which are the result of sudden and
proCtise loss of blood, the prognosis is grave, and this is especially so if
ibe palient is pulseless and convubions have occurred. In such in*
rtwtfffti^ eroo though the hci^morrhage has been arrested, it may be
tmiMdaibTe to save the patient.

62 DISEASES OF THE BRAIN.

In the gradually-developed form the prognosis is generally favor-
able.

Morbid Anatomy. — ^The vessels of the brain and its membranes are
observed upon post-mortem examination to contain less than the normal
amount of blood. The tissue of the brain is pale, and section shows a
diminished number of the red points in the white substance. Some-
times there is an increased amount of serous effusion in the sub-
arachnoid space, but the ventricles are generally empty.

Pathology. — ^The questions to be discussed imder this head are
similar to those connected with the same point in cerebral congestion.
That the quantity of blood within the crani\mi can be diminished as
well as increased admits of no doubt, and the fact that the symptoms
grouped together as indicating the existence of cerebral ansemia are
really the result of deficient blood-supply to the brain is equally certain.
The experiments of Kussmaul and Tenner,' as well as those of other
physiologists, are perfectly convincing.

To observe in man the effects of even temporarily cutting off the
supply of blood to the brain, it is only necessary to compress the
carotid arteries for a few moments. I have repeatedly done this in rab-
bits to the extent of producing insensibility and convulsions. Jacobi *
relates the following symptoms as generally observed in the human
subject : Dimness of sight, dizziness, stupor, weakness in the legs, stag-
gering, swooning, loss of consciousness, and sudden apoplectic falling
down.

Dr. Alexander Fleming ' tried the effect of compressing the carotid
arteries. " There is felt a soft humming in the ears, a sense of tingling
steals over the body, and in a few seconds complete unconsciousness
and insensibility supervene and continue as long as the pressure is
maintained. I have recently performed this experiment several times,
with the effect of producing similar phenomena, together with pallor of
the countenance, dilatation of the pupils, and temporary headache.

In many cases of cerebral anaemia, the cause, as we have seen,
resides in the blood-producing functions, and is such as to cause the
formation of blood which does not contain its due supply of red cor-
puscles. Here, although there may be no diminution in the actual
volume of this fluid circulating in the cerebral vessels, the effect is the
same so far as the nutrition of the organ is concerned, and hence the
symptoms of anaemia are slowly evolved.

Again, it cannot be doubted that spasm of the blood-vessels pro-

* " Untersuchungen iiber Ursprung und Wesen dcr fallsucbtartigen Zuckangen,**
Frankfurt, 1857. Also, " On the Nature and Origin of Epileptiform Convulsions, caused
by Profuse Bleeding," etc. New Sydenham Soeiety Translation, 1859.

* Quoted by Kussmaul and Tenner.

* British and Foreign Medico- Chirurgical Review^ April, 1855, p. 629, in a paper en-
titled " Note on the Induction of sleep nnd Anaesthesia by Compression of the Carotids."

CEREBRAL ANEMIA.

Ineed tJirough the sympathetic and vaso-motor nerves explains the
on^Iii aod continuance of many oases of cerebral antcaiia^ It is in this
way tliat mental cmotioas act, and sometimes with such rapidity as to
cause Instant death. This spasm may be kept up for a very consid-
erable period, with the effect of developing the ordinary symptoms of
cerebral aosemla, even after the emotion whloh orignated it has long
«ince disappeared.

Treatment — The first indication to bo fulfilled in the treatment of
oefebral amemia is to get rid of the cause. It often happens that this
is still in active operation when patients come under our care, and there
is no hope of permanent success till it is removed. Thus, if there is
iMsmorrhage from a divided vessel, from the uterus, the bowels, the
lungsi^ or other part of the body, it must be arrested ; if there is ex*
hausting discharge from the air*passageS| the intestines or the genital
it must be stopped ; if the digestive or assimilative organs do
01 perfectly perform their ofBces, they must be put in gocxi condition,
if a tumor or other obstruction to the due course of the blood to the
brain exist, it must be removed ; and if the hygienic conditions sur-
rounding the patient be bad, or the food inadequate in quantity or
[ity, they must be improved.

JS'o medicine exercises so powerful an effect in cerebral anrie^mia as
ftloohol in some form or other. Perhaps, all things considered, the spir-
itooiai liquors, such as whiskey, bra tidy, and rum, are more generally
tpplscabte^ For the influence is more rapidly felt, and there is not the
same rink of exciting or aggravating gastric disorder as when vinous or
malt Ikjiiors are usecL The quantity must be regulated according to the
ctrcuraatiuices of each case, and should always be large enough to
materially Increase the force of the heart.

Bat if this were the only effect of alcohol, its benefits in cerebral
, would be but temporary, and would certainly be followed by a
p * V -ion. Aside, however, from its stimulating action on

loncy is to improve the appetite and digestive power,
and in relax any spasm of tht) blood-vessels that may be present.

Occ&Siionall}' it happerts that alcohol is badly borne by amemic
ftti«*ntA^ The brain has for so long a time been deprived of a due
f its natural stimulus — blood-^that time is required to enable
r*ite, and be improved in tone by, the increasetl supply. Thus
f pliyxtcmn will find that in some oases the patients will be apparently
i^rtd veone by the remedy which of all oth«rs is calculated to do
mo«t good- The headaclje and vertigo are increased, th© general
ig of drbility and m/daise greatly augmented, and the complaint
! nmdtfi that the liquor has ** gone to the head,"
Now, it muHt bo recollected that the brains of anaemic persons are
ia t«fy much the same condition as the eyes of those who have for a
Bg time been shut out from their natural stimulus — light. When the

64 DISEASES OF THE BRAIN.

full blaze of day is allowed to fall upon their retinae, pain is produced,
the pupils are contracted, and the lids close involuntarily. The light must
be admitted in a difiEused form, and gradually, till the eye becomes
accustomed to the excitation. So it is with the use of alcohol in some
cases of cerebral amemia. The quantity must be small at first, and it
must be administered in a highly diluted form, though it may be fre-
quently repeated. Cases in which this intolerance of stimulants is
exhibited are almost invariably of long duration, and are as those in
which from a like cause wakefulness is produced by the recumbent
posture.

The carbonate of ammonia, or the aromatic spirits of ammonia, may
be given if there are any special reasons why alcohol should not be
used, but they are not to be compared to it in efficacy.

Li very extreme cases ether is preferable for the time being to any
of the foregoing remedies, on account of its diffusive nature ; and trans-
fusion may be necessary to save life.

My recent experience disposes me to put a very high value upon the
nitrite of amyl in the treatment of cerebral amsmia. Aldridge^ has
shown that it causes, when inhaled, dilatation of the retinal arteries ;
and the other phenomena of its action, the feeling of fuUness in the
head and the redness of the face and scalp, unite to prove that it exercises
a like effect over the vessels of the brain.

In the cerebral anaemia of weak and chlorotic girls it is especially
valuable, although there is no form of the affection, whether transitory
or permanent, in which it will not prove beneficial. Even a single dose
of four drops inhaled from a handkerchief has repeatedly in my hands
relieved anaemic headaches, and effectually dissipated syncope, the re-
sult of a feeble action of the heart. Upon one occasion I had, rather
imprudently, perhaps, acted in a case of goitrous cxophthalmia upon
the pneumogastric nerve with a galvanic current of too great a degree
of intensity. The heart was rendered exceedingly weak and irregular in
its pulsations. The patient, a lady, became insensible from syncope, and
was unable to swallow the brandy I held to her lips. I poured a few
drops of the nitrite of amyl on a handkerchief and held it to her mouth.
Immediately the action of the heart became stronger, the color began to
return to the face, and consciousness was at once regained.

In chronic cerebral anaemia, the nitrite of amyl should be admin-
istered in doses, by inhalation, of from four to eight drops three times a
day. This course may be continued as long as may be necessary, with-
out the slightest deleterious result. I have repeatedly persevered with
it for a year, in oases of epilepsy, with the happiest effect. It has never
in my experience been requisite to use it longer than a few weeks in
cases of cerebral amemia.

It may seem strange, with the cases I have given, and with the
» »* WeBt Riding Lunatic Asvlum Reports," vol. i., 1871, p. 77.

CEREBRAL ANEMIA.

Ige, from experiment and ophthalmoscopic examination, relative
to tbe power of the primiiry galvanic current applied to the brain or
sjxnpatbetio nerve to contract the cerebral blood-vessels^ that I should
reoommend the use of gulvanism m cases of cerebral aniBmia, Clinical
experience^ noweverj shows that it is decidedly beneficial, provided the
tension be very low. I am satisfied that not more than two or three
cellfl should be brought into action in such cases, and that the current
should only be passed for a few seconds at a time* It appears to give
increAsi^d tone to the vessel, and to promote the nutrition of the brain
in A remarkable degree,

Ab adjuncts to these means, the bitter tonics^ such as quinine,
gentian, columbo, and quassia, are useful. Iron is almost always re*
quired, though there are patients who do not tolerate it. In such cases
manganese may be substituted with advantiige, I have frequently used
the sidphater in doses of five grains, with excellent results. When iron
is boni«, I know of no better combination than that given on p^e 54-.
Cod4iver oil is also a valuable agent in the disease under consideration.

It must not be forgotten that food Is the most imi>ortant factor in
iering cbronio cerebral amemia. T!ie main permanent influence ot
jmnliinta and tonics is exerted upon the appetite and digestion, and
tbe bk>od and tissue forming functions mainly as an excitant. The
md strength must come from the food. This should, therefore, be of
gotui quality ; animal food such as milk, eggs, and meats of various
Idada, fonniog its chief portion.

The intfuenoe of position should always bo taken advantage of to
tmeSBt^le the flow of blood to the head, and the erect posture avoided
■a £ftr as possible, especially durbg the early stages of the treatment*
Thus the patient should be encouraged to pass a good portion of the
day in a recumbent position, and should be instructed to assume it at
onc9 on tlie oocurreuoe of any aggravation of the symptoms,

Thm opposite course is fraught w^ith danger. Physicians are often
aoxiottfl that their patients should take physical exercise, but it must be
fteRiemkered that those who suffer from cerebral anirmia have very little
▼Hal eQ^Tgy^ and a diminished amount of blood is circulating through
tb^ cv]gmn from which the greater part of their nervous power comes,
Ifiuctilar exercise lessens the energy, and still further reduces the
qiOBIllily of blood in the brain, for the muscles require an increased
sapply while in a state of activity. To* be sure, after the strength of
IIni system is in a measure improved, the blood increased in quantity
and quality* and the brain supplied with something like its proper pro-
poflioiit modermte physical exercise is of the greatest service,

1 have several times witnessed severe consequences from the as-
•ompikio of the sitting or erect position too soon after a profuse
bBmoiRliage, and to one case death resulted.

Am reganla mental labor, there is not much need of caution, for the
5

66 DISEASES OF THE BRAIN.

reason that it is impossible for the patient to undertake it to any d&
gerous extent. But, as he improves in strength, the desire to mal
use of his increased power may be manifested. It is, therefore, well
this time to prohibit any such exertion as will probably be foUowed I
marked depression. Moderate mental exercise is, however, far from fa
ing prejudicial, for it tends to increase the amount of blood in the bnd

Emotional disturbance should also, as a rule, be avoided, althou^
at times it may be productive of great benefit, especially if it be pc
sible to bring into action an emotion contrary to that which may ha^
produced the disease. Thus a lady became subject to cerebral ansemi
directly the result of painful emotions due to domestic trouble. Tl
difficulty was very suddenly removed, or rather the knowledge of its i
moval was suddenly communicated to her. The reaction was very grea
she was thrown into a state of joyous excitement, attended with consi
erable febrile disturbance, and I was apprehensive for a time that h
mind might become permanently deranged, for there were hallucinatio:
and delusions of various kinds, and many symptoms of cerebral conge
tion. But in the course of a few days, during which she was kept in enti
seclusion, and as far as possible from all mental and physical agitatio
she entirely recovered both from the secondary and primary disorders.

One word in regard to what not to do. From what has alrea(
been said in this and the previous chapter, the reader will have pc
ceived that it would be exceedingly injudicious to administer any of tl
bromides in the treatment of cerebral anaemia. I should not, therefoz
deem it necessary to say any thing further in regard to this point, b^
for the fact that I am very sure, from my experience, that wrong ide
prevail among some physicians relative to the subject. I see mai
patients affected with the disease under consideration, who have b«
treated with the bromide of potassium, and invariably with the effe
of aggravating the difficulty. Care in making a diagnosis and a kno^
edge of the fact that the bromides lessen the amount of blood in tl
brain are points which it is necessary to insist upon, even at the rii
of being tiresome by repeating what has already been said.

CflAPTER m.

CEREBRAL HEMORRHAGE,

Under the designation of cerebral hcemorrhage I propose to ooi
sider that disease which is often known as apoplexy, hemiplegia, or
paralytic stroke, and which is due to the rupture of a blood-vessel, an
the consequent extravasation of blood either into the substance of tl
brain or into its ventricles.

0£R£BRAL H^EMORBHAGE.

€3

Pwo formd of the affection, differing essentially only in the extent
or neat of the lesion, but presenting dillerent symptoms, ai*e to be dis^
tinguiAbed ; these are the apoplectic and fmralytic. In the first there
is loss o( consciousness ; in the second the mind, though perhaps im-
pairrtl, is not suspended in its action.

Symptoms. — Before the full development of the attiick there often
is^ for jieYeral days, a group of symptoms present which indicate cere-
bral disorder. These are very much of the same character as those
demoting the first stage of cerebral congestion, but, though generally
not so numerous, are far more striking.

Among the more obvious is a sudden difficulty of speech, arising
ifoni alight paralysis of the tongue and other muscles concerned in
irtaeiQistion. Words are not pronounced with the usual distinctness ;
the t<>ngue seems to occupy more space in the mouth than it should,
and ts not moved with the requisite degree of promptness and rapidity.

The other muscles on one side of the face may be affected, and
is a little distortion, lasting, perhaps, but for a few hours.
of sight may occur, usually characterized by the presence of
dark spots in the axis of vision. Such conditions are due to minute
sxtravasations in the retina?, and are always of most serious importance.
I ha^e known retinal clots to precede by more than a year the occurrence
of a more severe lesion.

Bleeding from the nose is a common precursor, and, when occurring
without being induced by severe muscular exertion, blows, a dependent
position of the head, or other obvious cause in a person over the age of
forty, is always to be regarded as a symptom of moment.

Nttmboess limited to one side of the body is of itself sulBcient to
cite apprehension. I have known several eases in which this symptom
the only premonitory sign. It may be present several days before,
or may precede the attack by only a few minutes.

In addition, there may be headache, vertigo, slight confusion of
tuind, a tendency to stupor, and vomiting*

KoDC of the premonitory symptoms may be present, and then the
Vittack, if of the apoplectic form, occurs w^ith great suddenness. Even if
Xhtj have been noticed, there is more or k^ss of abruptness in the onset,

Tliua the individual is perhaps standing, engaged in conversation,
wll«o he is instantaneously struck with unconsciousness, and falls to the
l^nnuid as if shot ; sensibility and the power of motion are abolished,
and no signs of vitality are apparent to the ordinary observer, with the
txoeptioa of the slow and labored action of the heart and respiratory
1ltii»cl<««. The breathing is steitorous, the lips and cheeks are puffed
Ottt with each expiration, and the pupils are generally largely dilated
tad inaensible to light.

Reflex movements are abolished at first, but after a few moments
y they reappear, and are even more readily excited thsn in health, owing

68 PISEASES OF THE BRAIN.

The voluntary power of swallowing is lost, but it is usually not dif
ficult to cause contraction of the muscles of deglutition by excitatioi
of the pharynx. When these cannot be produced, the prognosis is^ i
possible, increased in gravity, for the reason that the extravasation ii
probably in the medulla oblongata, or so situated as to compress it.

The urine and fasces are often evacuated involuntarily.

An apoplectic attack of this character usually terminates in deatl
without the patient recovering his intellect in the slightest degree. I:
life should be prolonged for thirty-six hours, the probability of a fata
termination is materially lessened. I have never seen a case of cerebra
haemorrhage that was instantaneously fatal, and, although from ana
tomical and physiological considerations I admit the possibility of suci:
instances, J am persuaded that they must be rare. Jaccoud^ expressei
the opinion that death is immediate in those cases in which the hsem<
orrhage is in the medulla oblongata, or in those which occur in botli
hemispheres. Dr. Hughliugs Jackson,' on the contrary, though conoed'
ing from theoretical grounds that haemorrhage into or near the me<
dulla oblongata might cause instant death, has never witnessed such a
termination; and Dr. Wilks' says that apoplexy is very rarely, if ever,
a suddenly fatal disease, no matter what part of the brain may be the
seat of the effusion. Among the reports of several thousand post-
mortem examinations at Guy's Hospital, there was but one in whicl
death was asserted to have been instantaneous, and that was a case oi
meningeal haemorrhage. Even this was doubtful, for the patient had
fallen some distance from the hospital, and was brought in dead.

I have several times had cases under my observation in which, il
was said, death had been as sudden as though the individual had beer
struck by lightning ; but careful inquiry and post-mortem examinatioi
have either shown that the observers were deceived, or that there ha<]
been no extravasation at all, death being the result of heart-disease.

Nevertheless there are instances on record in which haemorrhage
into the medulla oblongata has produced death with as much sudden-
ness as any other possible cause. Ollivier * cites a case which came
under his observation at the Salp^tri^re:

" Batandier (Jeanne £lisabeth), aged sixty-four, of medium height^
and inclined to stoutness, was admitted to the Salp^tri^re, for attacks oi
hysteria, with which she had been affected since her seventeenth year^
when her menses appeared. These attacks were very violent, and
occurred at each menstrual period. They stopped during a single
pregnancy at the age of thirty years, and disappeared altogether a1

* " Trait6 de pathologic interne." Paria, 1870. Tome premier, p. 166.

• " On Apoplexy and Cerebral Ilficmorrhage." " Rejuolds's System of Medicine." Lon-
don, 1868. Vol ii., p. 620.

» "Guy*s Hospital Reports," 1866, p. 178.

^ ** Traits des maladies de la moelle 6pinidre." Troisidme Edition, Paris, 1887, tome
ii., p. 140.

CEREBRAL ODUORRHAGE.

ftjrty, when lier menses ceased. Her intolligence had not become
«moUfily impaired; she had Xull power of speech, but complete deafness,
exjgtitijg emee infancj, rendered tlua faculty almost useless to her, and
the a< ' Iv communicated with others by means of signs. She w*as

reiy i % her gait was irregidar, but nevertheless there was no

{taimljsU, In all other respects her health was good. On the 28th of
October, at mid-day, while in the midst of a group of women, she be-
came very angry, uttered a cry, leaned against the wall, and then hU to
the ground. She was raised up^ but was dead,

" Autopsy forty hours after death, . , . The sinuses of the dura
mater were gorged with blood, the pia mater was strongly injected,
and easily detached from the cerebral substance ; the middle lobe of the
bfmm presented a well-marked depression ; the brain was firm, and of
p;M>d consistence; the hemispheres, carefully examined, presented a de-
cided injection of both the white and gray substance, but no htemor*
rluigio /oyer, old or recent ; the ventricles were empty, the choroid plex-
uses thin and granular ; the optic thalami and corpora striata healthy.

** After having divided the spinal cord below the medulla oblongata,
and baring removed the medulla oblongata with the cerebellum, and
the pons Varolii, a sanguineous clot, irregularly round, and tlie size of a
walnut, was discovered adherent to the posterior part of the medulla
oblongata, and extending above as far as the opening into the fourth
^L Teatricle, which it entirely closed. The pyramids were not injured, but
^r tlia olivary botlies were partly destroyed, the right more than the left.
The restiform bodies were entirely detaehe<l, and were found in frag-
oneota in the middle of the clot. The clot was removed and the source
erf the harmorrhage was discovered to be in the central gray substance,

I four or five lines below the inferior border of the pons Varolii, which
was a littlfj softer than nonnal, but which in other respects appeared to
be healthy, as did also the cerebellum. An enormous quantity of san-
gldnolent serous fluid filled the spinal canal, and flowed out in part from
tlie foramen magnum, and in part from the opening made in the spine
ipT tiie examination of the cord, which was healthy and non-injected,
■ ** Both lungs were gorged with black blood, but presented no traces
^ emphysema; the right cavities of the heart were tilled with black
bloody but the organ was healthy.
^^ ** AH the abdominal organs were in a normal coDdition/*

^1 OUivier remarks, in reference to this case, that death was as instan-

^ taocotts as tbougli produced by a sudden luxation of the first or second
▼ertebra,

Dr, A. Charrier * has reported the case of a woman who, on the

lipslflb day after deUvery, died instantaneously. At the evening visit,

nUa lalldDg, ** she suddenly uttered a crj', turned over on her pillow,

sod was dead* Death was as instantaneous as though she had been

1 - liAnorrlktgle da butbe nchidien.** AreAivm di phyni&lo^^ I86a, p, 660.

70 DISEASES OF THE BRAIN.

struck by lightning." At the autopsy a Email clot was found in tl
centre of the medulla oblongata. The rest of the brain and the hea:
were perfectly healthy.

In the majority of cases attended with complete loss of consciou
ness, the course of the disease is not so rapid or hopeless as in the fon
just described. The patient falls, is comatose, breathes stertorousl^
and presents a similar general appearance; but after a time conscious
ness begins to return, and it is possible to partially rouse him from th
condition of insensibility. He turns over in the bed, though with difl
culty, and may attempt to speak. Articulation is, however, indistinc
for the muscles of one side of the face are paralyzed, and the tongu<
from a like cause, is restricted in its movements. The paralysis is foun
to exist in the limbs of the same side, and involves the loss of sens
bility, as well as of motion, though rarely to the same extent. In som
exceedingly rare cases, perhaps not clearly understood, the paralysis c
the limbs is on the opposite side to that of the face. A man thus aj
fected was present at my clinic, in October, 1870, at the Bellevue Hoi
pital Medical College. He was a patient imder my charge at the Ne^
York State Hospital for Diseases of the Nervous System, and had bee:
attacked several years previously. His history, as elicited with grea
care by my clinical assistant and resident physician of the hospital, D]
Cross, was perfectly clear on this point.

The facial paralysis presents several points of great interest in
diagnostic point of view. The affected side is incapable of expressiox
but, so long as the patient does not attempt any facial movement!
scarcely any distortion is perceived. Should he endeavor to open hi
mouth to spit, or to puff out his checks, the paralysis is at once noticed
Owing to the fact that the antagonism of the muscles is destroyed, th
face is drawn toward the sound side, the angle of the mouth beiD|
slightly depressed. It is remarkable, however — and the fact is of im
portanoe as a diagnostic mark between the facial paralysis of cerebia
haemorrhage with hemiplegia and the simple facial paralysis from injur
or disease of the seventh pair — that the patient does not lose the abilit;
to close the eye of the affected side.

If the fifth pair of nerves is involved in the lesion, sensibility is im
paired, which is never the case in simple facial paralysis, and the ma£
seter and pterygoid muscles, which receive their motor influence iron
this nerve, will consequently be paralyzed* The ability to masticate O]
the affected side is therefore lost, and the cheek hangs lower than oi
the sound side.

The tongue is also only paralyzed upon one side. When, therefore
it is protruded from the mouth, the point deviates toward the paralyze<
side, owing to the uncompensated action of the sound genio-hyoglossus

All these paralyses occur on that side of the body opposite to th<
seat of the lesion. In a very few instances the paralysis has existed oi

CEREBRAL HEMORRHAGE.

same side with the lesion. This is explained bj the fact that it oc-

ioDally happens, as Longet * states, that the decussation of the an-
twior columns of the cord is imperfect. At timeSj agnin, owing to a
double extravasation, or to the fact that the lesion is in the mesial line
of the pons, or that it forces its way so as to involve both hemispheres,

h «idcs of the body are deprived of motion.

Very inexact ideas have prevailed relative to the temperature in
ouet of cerebral haemorrhage* The researches of Boumeville* have
^ren us more certain data than we previously possessed, and^ aside
firotn their value as contributions to symptomatology and pathology, are
of gr^ttf importance in the matter of prognosis* This observer, as the
rr;«ilt of numerous determinations, arrived at the following conclusions:

That the animal temperature, in the very Inception of the apoplectic
allaek, undergoes a verj' considerable reduction, the thermometer in the
i^lotn indicating 36** (=96.8° Fahr.), and even sometimes falling as
low as 35.4° {^95,72^ F.). This reduction seems to be influenced par-
tteolarly by the continuance of the ha-morrhage and the supervention
of ftddiUoDid centres of extravasation. To this period of temperature-
drpreasioQ succeeds another, during which the atiimal heat remains sta-
tkmary ^t its normal point, K the patient is destined to recover, this
period ia prolonged indefinitely; but, if death is to ensue, a third period,
chAmctcrized by a remarkable elevation of temperature, 8iipervenes,
DursDg this stage the thermometer ioditjates 40^ (= 104*^ Fahn), or may
T»e to 41.5^ (= loe.r Fahr.).

Charcot ' has called attention to the fact that, in a few cases of cere-
bral faiemorrhage, an acute bed-sore forms on the buttock of the para-
Jjri^ mde. From the second to the fourth day after the occurrence of
the Aitaek, an erysipelatous redness of irregular outline occupies the
buttock, and frequently extends over the greater part of its surface,
ithin forty-eight hours a dark-colored spot appears on the central
ion, and the epidermis of this is raised by the sanguinolent fluid be-
ll, HiLi reside breaks, and a sore is thus formed, which gradu-
ally lixtooda. Occasionally but very rarely the sore occurs on the sound
buttock. I have only witnessed two cases in which these sores were
fonaied, and both were in persons over seventy years of age. Of course^
Uie^e ^echars are not to be confounded with the bed-sores due to lon^
coottotiod pressure,

li is ranJy the case that the third nerve is affected* "WTien it is,
tiwre ta external strabismus from paralysis of the internal rectus muscle,
-and pto«s from paralysis of the elevator of the upper eyelid. The
pitpti ta dilat<Hl, and is insensible to light.

^ ** AaAlomie «1 {kh}^iot(»gie da STfitStne nenreux/^ tome I, p. 383.

* ** £tiid«0 clitUquGA «t iti«>mi€>m6trtqua siir les Eaakdied du sjst^me DenreinL^ PaHs,

* ** Bar U fomiftttcm r»pide d*uiio eschiire i 1ft fe«M da cot6 pftrft1y«d djmfl rh^flaipUg^e
yiciaii 4a came eMbrali».'* Archk^t* dt phjfmlogU^ 1868, p. 308.

— the i
H kultc

^^^9ort]<

DISEASES OF THE BRATN.

Another pbenomenon is sometimes obserred, and that is the rotation
of both eyes toward the sound side. This is accompanied by a like
moveraont in the head^ so that, if tho patient is paralyzed on tii(^ loft
side, the eyes and head are turned to the right, and consequently, as
the patient lies in bed, the right side of the face rests on the pillow. I
have observed these symptoras in about one-third of the cases of cere-
bral ha?morrhage which have come under my observation. They were
present from the very beginning, and disappeared in a few days.

Slight convulsive or involuntary movements are occasionally noticed.
The most frequent of these is yawning, a symptom which Dr* Todd '
reganls as troublesome, and even unfavorable, but which, in my experi-
ence, is not very anno^ang or dangerous. The other convulsive actions
may be on tho whole of either side of the body, or on both sides, or
may be restricted to a single limb or even a group of muscles.

Reflex movements are at first sometimes abolished, but subsequently
can generally be excited, especially in the lower extremity, by tickling
the sole of the foot. Deglutition, tliough imperfect, can generally be
made to take place by reflex action, unless, as previously stated, the
hsemorrhage is in, or in the vicinity of, the ujedullii oblongata.

Strong tonic contractions of the muscles of ti^e paralyzed limbs are
occasionally a prominent phenomenon. The upper extremity is more
apt to be their seat than tho lower, and the biceps and triceps muscles
are especially liable to be thus affected. This condition may exist at
the very beginning of the seizure, or may subsequently supervene.

Few systematic authors have noticed the P\Tnptom in question—*
symptom which is not to be confounded with the secondary contractioiia
coming on several weeks after the attack, and the origin of which ia
altogether different— attention seems to have been first called to it by
Boudet,* but Durand-Fardel * studied it more thoroughly, and w*as the
first to determine its connection with a definite lesion* Accor*ling to
this later author, primary contraction is only present in cases of cere-
bral haemorrhage, when the extravasation reaches the ventricles or the
subarachnoidal space. So long as the blood remains circumscribed in
the cerebral tissue, there are no contractions either in the paralyzed or
the non-paralyzed limbs. Of twenty-six cases of cerebral hjrmorrhage,
in which death ensued within one month, and in which tho ventricles or
the meninges had been invaded, there had been, in nineteen, contractions
of the paralyzed members; in three, contractions of the sound limbs;

and in four, resolution without contraction. Cfmrcot,* in fourteen caaea

«
1 "Qiaicd Lectures." Beeoad edition. London, isei, p. 708.

* ^* H^moire but Vh^morrhMfjie dea mdiungefl.^' Jounm! dt» cotmainam/om mifeflu
ehirurffkai^t 1830.

* '' De U eontraetioa doaf rhliiiorTluiglo o^r^bmle.*^ Ar^^hiva ff^nhttUt de mSdeck^
1843, tome \l, p. S40. Also *" Maladiea des viem&rds." Ptim, 187S, p. 225,

^ '* youvellea r^cherchcfl sur la pathog^nie de Fh^moiTbagie c^r^brale.'* ArcMvm d$
ph^HohgU^ 1868, p. 110.

4
I

CEREBKAL H^UORBHAOE.

Tcuiur ur meningeal invasion, noticed contractions in eleven, and
in two epileptiform convtJsions. The contractions take place whether
tbe tnembr&Des be distended by the clot, or ivhether rupture ensues.

In the less severe apoplectic furm of cerebral hirmorrhage now under
consideration, the mine and faeces are sometimes passed involuntarily
I from paralysis of the sphincters, and are at times obstinately retained
'Itdih paralysis of the bladder and abdominal muscles.

The mental symptoms are at first scarcely distingiiishable from those

which are present in the severest form of the disease. The coma and

insensibility are complete, but after a time, which varies in duration

r with the extent of the lesion, consciousness begins to return. The |m-

Hient opens his eyes, and gives a little attention when loudly spoken to;

and is perhaps able to express, to some extent, his wishes by signs and

L Gradually the mental power increases; he attempts to speak,

\ v^ords are misplaced or forgotten, and his articulation, owing,

as already stated, to the paralysis of the face and tongue, is thick and

[ indistinct. Those words which are enunciated by the movements of the

ips and tongue are especially troublesome, while those formed in the

iiroat are not difficult to pronounce.

The mental characteristics of the patient will be found to have un-

?ne a radical change. Ho is irritable, unreasonable, and fretfuL

' of the proprieties of life, which may in health have been very

becomes obtuse; his memory is notably impaired, and his rea*

aoning power greatly diminished. The greatest change, however, is

I ' I in the emotional faculties. He laughs at the veriest trifles,

*i i> tears profusely at the least circumstances calculated to annoy

him. Even for years afterward this peculiarity is noticed.

Such is the first stage of an attack of cerebral hiiemorrhage marked
by spoplexy and paralysis, as ordinarily observed when amendment
kdt phtce. It is often the case, however, that this stage is not fully
eloped, owning to the eontinuance of the haemorrhage. In such an
eteot Ibe coma becomes more profound, the breatliing more irregular
lets frequent, the pulso intennits and loses in force, the face be-
es purple from imperfect aeration of the blood, and death ensues,
otlier oaaes a certain degree of in^provement may be attained, and
ttk the hasmorrhage may recur, and the patient dies coinatose.
Ill II few cases which I have hatl under my charge, the first s^Tnptom
red lias been intense pain in some part of the head. This has been
ly followed by nausea and the ejection of the contents of the stom-
ftcb* Thero have also been slight wandering of the mind, and a disposi-
tion to stagger in walking. These phenomena have persisted for from
four to atJL hours, and then the patients have gradually passed into a
itose condition, with general resolution of the limbs. Death has
aed within twelve hours after the beginning of the symptoms. In
I of these cases, that of a gentleman of this city, he had remarked to

74 DISEASES OF THE BRAIN.

me, at six o^clock in the evening, that he was feeling remarkably well
all day. For several years he had suffered from cerebral hypenemia,
the result of continued and severe mental application. At about eight
o'clock he was seized with the most agonizing pain in the head, at-
tended with intense nausea. Repeated vomiting took place, and there
had been slight delirium and momentary periods of forgetfulness. My
friend Dr. Lente, of Cold Spring, who was in my house at the time,
went with me to see him, in response to his message that I would calL
We found him as above described; and, as he was firmly convinced that
his stomach was at fault, an emetic of salt-water was given him. It
acted promptly, but without affording him the least relief. A hypoder-
mic injection of a third of a grain of sulphate of morphia was next ad-
ministered, but without benefit; and this was followed by a similar
quantity after half an hour. He then thought he mi^t sleep a little,
but the pain continued. An hour afterward I left him, being of the
opinion, in which Dr. Lente shared, that he was either suffering from a
cerebral tumor or an extravasation of blood. Two hours afterward I wm
ag^n sent for. He was then comatose, the limbs in a state of resolution,
the breathing of that loud, rauchous character, and the heart beating
with the irregularity so indicative of effusion into, or in the neighbor-
hood of, the medulla oblongata. Deglutition coidd not be excited by sub-
stances placed in the mouth. The right pupil was strongly dilated, while
the left was a mere point. Death ensued within two hours afterward.

The post-mortem examination was made the next day by Dr. S. D.
Powell, in presence of Drs. Lente, Ripley, Elsberg, and myself. A
clot the size of a small orange occupied the posterior part of the middle
and central portion of the right lobes. It was entirely con6ned to the
white substance. Another, about as large as a hickory-nut, was situ-
ated in the right half of the pons VaroliL

In all probability the clot in the right hemisphere began to form
first, and that the second, into the pons Varolii, which was the ijnmedi-
ate cause of death, did not originate till a considerably later period, in-
dicated by the disturbances in the respiration and circulation, and the
impossibility of exciting deglutition.

In those cases in which the improvement has been progressive up
to the point of partial resumption of the mental faculties, we find that
a second stage characterized by different symptoms often supervenes.
This is the period of infiammation.

It may begin at a variable time after the occurrence of the extrava-
sation, usually not later than the eighth day. It is marked by febrile
excitement and pain in the head, the latter being often very severe.
There is gastric derangement, as evidenced by nausea and vomiting ;
and convulsive movements of the limbs, with contractions of the flexors
of the paralyzed side, are generally present. Delirium is also a promi-
nent feature. Sometimes there is obstinate wakefulness, and at othen

CEREBRAL H^MOBRHAGK

(jg tendency to coma. Tliis stage may last three or four days, or

at mo»t five or six, when it either causes death by extension of the in*

rflaaiin&tion from the immediate vicinity of the lesion to other parts of

the brain, terminates in the formation uf un abscess, or g'radually ends

in i^solntion, with abatement of the symptoms.

Disregarding for the present the first two of these results, we proceed
f^ih the consideration of the phenomena of a case in which resolution
I tAk68 place.

With the cessation of the inflammatory action, the improvement of
tbo patient becomes very marked. His speech is every day more fjis-
tinct, his mind more active, his paralyzed limbs more capable of motion*
Usually the leg recovers power with much greater rapidity than the arm,
and thus the patient is able to walk tolerably well before he can raise his
arm from his side, bend the elbow, or extend the fingers. Tlie paralysis
in the leg is most marked in those muscles whoso office it is to elevate
the footv, and this necessitates a peculiar gait in order to avoid dragging
f the toes along the ground. The abductors are rarely affected to any
it extent, Tlio patient in walking, therefore, throws the leg out
from the body, and then, swinging it around, clears the ground in this
rjUAiiAer.

In the upper extremity there is almost invariably a dispoaition tow-
lard contratTtion of the peetoralis major and minor muscles, by Avhioh the
I b drawn across the front of the thorax. At the same time the latis-
«ii9 dorsi, the trapezius, the rhomboidei, the teres major and minor,
generally in a state of relaxation, and eventually tend to atrophy.
tie elbow h sliglitjy flexed, the wrist bent upon the forearm, and the
\ drawn in toward the palm of the hand. These actions may, in a
measure, be prevented by appropriate treatment, and they may
F^ary in extent according to the gravity of the attacks It is a curious
[•fact that the muscles of respiration are never paralyzed in cerebral hicm-
rcMrbag^ unless the medulla oblongata be involved,

Troaaaeau * has insisted, with great force, on the fact that, when the
regains power before the leg, the termination is always fatal. That
it the general result, 1 am very sure from my own experience, but it
t not invariable, for there are now in the New York State Hospital for
of tlje Nervous System two patients affected with cerebral
^niiage whose arras have improved to a very great extent, while
IImi lf»gii are still as much paralyzed as ever.

Now, mth all these troubles of motility, sensibility may likewise be
lorolred to a greater or less extent. When this is the case, the limbs
of tbe afflicted side at first feel heavy as If made of lead, and after a w4itle
atiitibness, as exhibited by a feeling as if ant^ were crawling over the
(ilciti, or water trickling over it, as if pins and needles were sticking in it,
ar aa if that part of the body were " asleep," is noticed- Sometimes the
* •'Lectnra on CUaioal Itedidae.*' Baure^s TruuBlatioii. FartL Loadoo^ 1860, p, 10.

DISEASES OF THE BRACT.

sense of touch is greatly lessened, wliile the ability to feel pain is soaroely
impaired, and indeed is often considerably increased. Again, there may
be hy|>era*sthesia of the skin of the affected regions, and pain along the
course of the nerves.

The circulation is inactive in the paralyzed, limbs, and this, together
with the deficient nervous power, tends to cause a permanent reduction
of temperature. The difTerence may amount to as much as five or six
degrees, and, as the ability to resist cold is diminished, the patient is
obliged to use additional covering on the paralyzed members,

, From continued disuse, atrophy of the paralyzed muscles always
takes place unless suitable treatment be begun at an early period.

Thus far we have only considered those attacks of cerebral
orrhage which are accompianed with unconsciousness. One of these
Jomis kills, without the patient so far recovering as to show whether he
i paralyzed or not, though cf course he is so to a profound degree ; the
other allows of more delay ; the brain can still act to some e^ttent, and,
if death does not ensue from continuauce of the hiemorrhage, the pa-
tient is found to be paralyzed on the side of the body opposite to the
seat of the brain-lesion. One other form requires notice, and it is, per-
haps, the one most frequently met with. It diif ers from the attacks just
described, in the important fact that it is unattended with unconscious-
ness.

Like tlie others, this species of cerebral lia?morrhage may take place
very suddenly, without premonitory symptoms, or it may, like tbemi
happen while the patient is said to be asleep. Generally, however, though
there may be no long prodromatic stage, there are symptoms occurring
immediately before the attack which indicate both mental and physical
disturbance. These are headache, vertigo, numbness, vomiting, irrita-
bility of temper, and, perhaps, slight difficulties of speech.

When the attack comes, the individual, if standing, falls, from the
immediate paralysis of one leg. lie is fully sensible of his condition,
although there is generally more or less mental change. The arm and
face are affected, and the speech is rendered impossible or indistinct.

If the patient be sitting or lying, he is aware that something has
happened, but does not discover its exact character till he attempts to
rise, A distinguished general officer of the army, after a fatiguing day
of ceremony, entered his carriage with his wife, to be driven to his
hotel. As he passed along Fifth Avetme, he felt an indescribable sen-
sation, and immediately afterward noticed that he could only see the
half of objects. He made no effort to speak, though he is confident he
did not for a moment lose his consciousness. When he attempted to
get out of the carriage, he found, to his suqDrise, that he was paralyzed
on the right side, and that his speech was so much Impaired that he
could not be understood*

Another gentleman was reading an amusing book, at which he

CEREBRAL O^MORREAGE.

bcci heartily. He felt suddenly a feeling of vertigo, and the book
dfOpped from his hand. He attempted to pick it upj but found he had
lost power in the anu, and, on trj^ing to call to his wife, who was in the
same room, discovered that he could not speak. At this time he could
walk, but in a moment or two afterward he fell, from paralysis of his
leg. So far as( the paralysis is concerned, I have rarely seen a more
severe case than this.

Another went to bed, perfectly well, to all appearance, having en-
joyed uninterrupted good health for several years. In the morning he
arose, but felt a little pain in his head. As he stood befope his glass,
lie thought his face was slightly twistoil, and he noticed as he was shav-
ID^ himself that he did not feel the razor on one side. While he was
fisting his facial mobility and Bensibility, he experiencetl a trace of
numbness in his left hand« This gradually increased, and in addition
the limb lost power. In a few minutes he coxdd not move it at all.
By the time I saw him — ^two hours afterward — the paralysis had ex-
tended to the leg. At no period was there insensibility or mental
oonfasion.

A gentleman retired at night in good health. On attempting to
get oitl of bed he discovered that ho was paralyzed in the leg. Neither
Um» arm nor the face was aflfected.

In the case of a gentleman of this city whom I saw in consultation
with Dr. W. M. Polk, and wlio had for several years suffered from fru-
qticnt serere headaches and other cerebral symptoms, the only phe-
-n was binocular hemiopia, with occasional slight delirium. Dr.

II ^', who saw the patient before I did, discovered no alterations

in the functions or structure of the eye, and we all agreed that the case
was cine of very slight cerebral haemorrhage.

Several cases have been under my care in which only the face or tho
toii|Q^« was paral^Tted; others in which the arm alone was involved; and
olbent, like the one just mentioned, in which the symptoms were con-
fined entirely to the leg. Sometimes there was a momentary feeling of
tertigo, sometimes a vacant stare, something like that of the petit mat
of epilepsy, sometimes a slight degree of intellectual confusion, some-
tiESirs headache, and, again, no head-symptoftis whatever. The sub-
•eifoent progress of such attacks requires no special consideration
beyond that already given to the more severe forms.

Now, no matter how light the attack may have been, nor how rapid
ike improvement, the patient who has had cerebral haemorrhage is never
afiot^y or physically the same as he was before. If the seizure has not
' re, he may advance so far toward a complete cure as to evince

' tUsorder of his mind or body. But close observation shows

llut he is not entirely restored, and, though he may do very well for light
tfil^Uectnal and physical exertion, severe labor of either kind is beyond
his powcra^ — and no one ia more sensible of this fact than himself. Even

DISEASES OF THE BRAIK.

after years his emotions are abaomially excitable, A patient now it
the New York State Hospital for Diseases of the Nervous System in-
fonns me that he sheds tears every time a funeral passes liim, and that
even hearing of any one's death, or reading the obituary cokimn in a
newspaper, causes his feelings to get the better of him. In the lighte-st
forms of the attack, this easily-aroused emotional disturbance is a marked
feature for years subsequently, if it ever entirely disappears. And as
regards the muscles which have been paralyzed, it is very certain that,
though they may be made strong enough for all practical purposes,
they never can be restored to their former sound condition.

The character and general mental type of the individual usually
undergo some change ; and this may be to the extent of reversing hit
ordinary traits.

Causes, — Advanced age is one of the most influential circumstances
which predispose to an attack of cerebral hemorrhage, and this fact has
long been known. Thus Hippocrates* states that apoplexy is iBoet
common between the ages of forty and sixty, and modem investigatioa
establishes the truth of the proposition as regards the actual number of
cases. It is probable, however, that the liability increases^ as Dr, Flint *
says^ from the age of twenty upward, and that there are not so many oases
occurring in persons over sixty as below, for the reason that the numb^air
of individuals alive of that age is less.

Of three hundred and eighty -three c^sea of cerebral hemorrhage which
have been under my professional care, at some time or other after the
occurrence of the extravasation, in my private and hospital practice,
and in w^hieh the age of the patient is noted, three hundred and forty-
one occurred in persons over forty years of age. Of these, three hun-
dred and eleven were between forty and sixty, thirty-three between sixty
and seventy, five between seventy and eighty, and three over eighty.

Of the thirty-one cases in persons under forty, twenty were between
forty and thirty, ten between thirty and tweiity, and one under twenty*
Thia latter was a boy of seventeen, whom I exhibited at my clinic At
the Bellevue Hospital Medical College in the autuum of 1870.

The disease is certainly more common among men than women,
though some authors have asserted the contrary. Falret ascertained
that, of twenty-two hundred and ninety-seven cases, sixteen hundred
and sixty occurred in males and only six hundred and thirty-seven in
females. In my own experience, of three hundred and eighty-three
eases, two hundred and fifty-nine were in males and one hundred and
twenty-four in females.

Temperament and organization are supposed to have an influence
in predisposing to cerebral hfrmorrhage. It w^as formerly thought that

' ** Aphorisms/* cbftpter vi.^ apborism 67.
* " A Treatise on the Principles and Practice of Medicine"
delphia, 1868, p. 682.

Third edition, FhUa*

CEREBRAL HEMORRHAGE.

of san^oinc temperament and plethoric habit who had stout bodies,
heads, florid complexioDs, and short, thick necks^ were especially
►le ; but more exact and thorough investigation would appear to show
; such ia not the case, and that thin and pale individuals show fully
[ gTOftt a proclivity. Dr. Flint * expresses the opinion that there is no
etal apKjplcctic constitution, and my own experience is decidedly to
^t!ie same effect.

That the tendency to cerebral haemorrhage is often hereditary,
ppears to be very certainly established. Within my own knowledge,
! am aware of several striking instances which support this opinion. A
gentleman consulted me for hemiplegia, the result of cerebral hsemor*
_liuigc, whose grandfather, father, two uncles, two brothers, and one
aster, had died of this disease, and whoso son, t!iirty-six years of age,
been attacked. In another case a lady had her father, two broth-
trs, and one sister, die of the disease ; and, in a third very remarkable
pj the great-grandfather, grandmother, father, four uncles and aunts,
and two brothers, all in a direct line, died of cerebral hiemorrhage.

Piorry * cites the case of a woman, herself paralytic, whose three
children had died of convulsions, and whose mother, uncle, and brothers
[And sisters, to the number of twelve, had died of cerebral lueinorrhage
for convulsions. It has very often happened in my experience that the
father or mother of a hemiplegic patient, whose condition resulted from
brml hflemorrhage, had been affected in a similar manner.
As regards the influence of diseases of the heart, I^gallois, Brlche-
tean, Hostan, Andral, and Bouillaud," adduce instances in support of the
r existence of a definite relation. While others, among whom Roehoux,
fTalshp-^ and Flint, are to be placed, deny the existence of any such caiisa-
Eifluence« As tending to produce active or passive cerebral conges*
{ disease of the left or right side of the heart would reasonably seem
to be CQndactve to the occurrence of cerebral hspmorrhage. The tension
V* *\ * * fod in the vessels of the brain is increased thereby, and the
fli 1 > the rupture of a diseased vessel rendered greater.

The c<indition of hfe has also been supposed to exert an effect in

pi-. .lUT...H,f,g to cerebral haemorrhage, it being asserted by some au-

111 it the affection is much more common with the rich, and those

', luxury, and refinement, than in the poor and laboring

It 18 difficult to arrive at any very definite conclusion on this point,
ovfalif to very obvious reasons, but I am inclined to think the theory to
be not well foundecl It is only necessary to visit our large hospitals,
to »ce bow many of the inmates, drawn as they generally are from the
labortng classes, are suffering from cerebral haemorrhage or its effects.

Thus far we have only considered the more important, intrinsic,

» Ofh rtl., p. S83, « "De rh6r^>dit6 daaj lea roakdies," p, 107.

** Tmit^ dc clialque dea mAkdiea du c<sur,* ' second et^tion, tome ii, p. 5S0.

DISEASES OF THE BRAIN.

predisposiiig^ causes ; there are, however, others which may be called
extrinsic.

Season is one of the chief of these. The disease is much luore
common in winter than in the other seasons, although some statiatica
would seem to show more cases during summer. A careful examination
of such, however, shows that under the head of apoplexy is included
not only cerebral haemorrhage, but congestion, sunstroke, embolus, and
in fact nearly every other affection attended with sudden loss of con-
sciousness. My own researches have been very exact on this point, and
as their results I find that, of the three hundred and eighty-three cases
of which I have notes,, one hundred and forty cases occurreil in winter,
eighty -one in spring, ninety-seven in summer, and fifty-eight in autumn.
It has been noticed, too, that sudden variations of temperature, especially
from mild to cold weather, increase the number of cases of cerebrml
h«?inorrhage.

Of the exciting causes, a long list can readily be made. Amon^
them are the excessive use of alcoholic liquors and other stimulating
substances; the use of opium in excess ; the ingestion of large quantities
of food, t»specially such as is stimulating and intligostible ; excessive
physical or mental exertion, strong emotional disturbance, such as anx-
iety, extreme joy, anger, or terror ; the act of coition, especially in old
people ; straining at stool ; enlarged prostate^ or paralysis of the
bladder, requiring strong muscular efforts for the evacuation of the
urine ; childbirth ; tight clothing about the neck, chest, or abdomen ;
certain occupations which require the head to be depressed ; vomiting,
sneezing, coughing, and laughing ; exposure to the direct rays of the
sun or other sources of great iieat ; the sudden arrest of a custoni-
ary fiux, such as hsemorrhoidal bleeding ; the sudden application of
cold water to the body ; long-continued bathing in very warm water |
the circumstance that the patient has had a previous attack, and certain
diseases, as gout and syphilis.

In regard to some of these causes, I may state that several very in-
teresting cases have occurred in my own practice. In one, a lady was
attacked on hearing that her cook had left her; in another the emotion
excited by the fall of a picture from the wall caused a seizure. Four
cases produced by straining at stool have come under my observation*
In one of them a gentleman well known in public life retained sufficient
consciousness and intelligence to take a large key out of his pocket with
the non-paralyzed hand, and to rap on the floor for assistance.

Two cases occurred during sexual intercourse, one in a man, the
other in a woman. In one of these there was, subsequently, a great
increase of venereal desire. In one case, the seizure was induetHl by
stooping over to tie the shoe. This was in the boy, seventeen years of
age, already mentioned. It must be confessed, however, that very fre-
quents, ]>erbaps in the majority of cases, no immediate cause can be

4
I

CEREBRAL HEMORRHAGE-

loiv aii«?ged. Of the three hundred and eighty-three cases noted
by myself, no cause was noted in two hundred and ten,

Kclative to the influence of sleep, I am by no means in accord with
those authors who regard it aa a powerful exciting cause. During sleep
Ibe <}uautity of blood circulating in the cerebral blood-vessels is dimin-
ilhed, and hence there is less tension upon their walls than duiing wake-
ftilii«ss. I doubt very much whether cerebral hii^morrhage ever occurs
during healthy, undisturbed sleep.

Bat there is a condition which suf>er\'^enes upon sleep, and which, to
onliiiarj observers, presents the usual phenomena of sleep, but which is
raally a very different state, both as regards the brain and the symp-
toms— and that is stupor due to venous congestion* In this affection
there is an increase of the pressure upon the brain, produced by the over-
distended vessels; and hence coma, to some extent, ensues. This state
is characterized by difficulty of awaking the individual, by turgescenco
of til© larger veins of the neck, by a more or less purple hue of the face,
by adoring, and by the puffing out of the lips and cheeks in breathing.
Both of these latter phenomena are due to paralysis.

In this condition it is not unusual for cerebral hiemorrhage to occur,

■ but the existing state is not sleep.
So far as my own experience extends, I have not found a majority of
the caHi>s, where I have examined into this point, to have taken place

L either during sleep or the stupor to which I have referred. I have made
it a ml*?, not only in those cases of cerebral hiBmorrhage which have been
under n»y own care, but all others, in which I could do so» to inquire
particularly with reference to the matter in question, and have found
that, ill three hundred and eighty-five out of four hundred and sixty-
Itve^n ca«e9^ the individuals were awake at the time of the attack.
I Doubtless much of the confusion has arisen, not only from the nonr
diflcninifiatiou of sleep from stupor, but also from treating of apoplexy
A8 a dtaeaae instead of regarding it as a symptom due to several very
different pathoiogical conditions of which cerebral haemorrhage is only
ooe, ami of which embolism, thrombosia, congestion, meningeal h:em«
■ otriiag^, and epilepsy, are others.

^m Miially, it may be said of the etiology, that whatever tends to in-

^^ cre«ao the ilow of blood to the head, or to retard its exit, is capable of
a<ttitiy as an immediate cause of cerebral hn^tnorrhage.

Dla^oaiS,— The diagnosis of cerebral hrr^morrhagp is ordinarily not
diffioaft^ but it must be confessed that one or two affections are very
Gftblp to be confounded with it^ and the attendant circumstances sur-
i patient in a condition of insensibility may be such as to
increase the obstacles to the formation of a correct opinion,
llitta, supposing an individual to be found in a state of profound in-
tvoaibility, the condition may be due to compression from injury of the
dcoD, to oofumsaion from a fall or blow, to congestion, to asphyxia, to
~ 6

82 DISEASES OF THE BRAIN.

syncope, to a recent epileptic fit, to ursemic intoxication, to hysteria, to
narcotism, or to drunkenness.

A mistake of either of these states for cerebral haemorrhage would
be, in the end, embarrassing to the physician, and perhaps injurious to
the patient.

The coma might also be the result of embolism, of thrombosis, of
tumor, of abscess, or of meningeal haemorrhage ; but, as regards these
conditions, no opprobrium could be attached to the physician, or harm
come to the patient, by any error of diagnosis, although a regard for
scientific exactness should always prompt us to be as specific as possible
in our inquiries and examinations.

From asphyxia, cerebral haemorrhage is distinguished by the fact
that in the former the respiration is suspended. The cause is often
apparent. A careful examination of the cranium, and a survey of the
surrounding circumstances, will enable the physician to ascertain the
existence or non-existence of compression from traumatic cause. This
cause may either be depression of bone, the rupture of an internal
blood-vessel, or the entrance of some foreign body, as a bullet, into the
interior of the skull. So far as symptoms are concerned, there might
be considerable difficulty in diagnosticating either of these accidents
from cerebral haemorrhage,* but the history would render a mistake im-
possible.

Concussion presents more difficulties, because the comatose person
may be found in such a situation as to warrant the opinion that he has
fallen from a height, or otherwise received a blow on the head, when in
fact he is suffering from cerebral haemorrhage. But if he has fallen from
a height or been struck, there will probably be more severe bruises about
his person than if he is affected with cerebral haemorrhage, and there may
be bleeding from the ears or nose — symptoms of cranial injury not met
with in the latter condition.

If, however, the individual has fallen from a height, he may have
done so in consequence of an extravasation of blood in his brain, and
he may present all the marks of suffering simply from the concussion,
or he may have fractured skull with compression. It is, therefore, im-
possible to make a correct diagnosis in all cases, or to lay down any
certain rules which will constitute infallible guides. It is perfectly
possible to meet with cases such as those referred to, in regard to which
no human judgment can be certainly correct. Such instances are of
course rare, and accordingly, in the great majority, the circumstances and
the presumption will generally lead to a correct opinion.

From congestion of the apoplectiform variety cerebral haemorrhage
can generally be distinguished without much difficulty. The absence of
stertorous breathing^ the short duration of the coma, the transient
character of the paralysis, the contraction of the pupils, the fact that
the loss of sensibility and the power of motion are not generally confined

CEREBRAL HEMORRHAGE.

(* side of the body, and the longer continuance of premonitory
•jf^ptoms, will be sufficient indications of the existence uf congestion.

■ Syncope is distinguished by the circumstances that the respij*attou and

■ circulation are both dimiiushed in power if not suspended, that there U
no hemipiegia, that the face is pale, the skiif cold, and that these phe-

H iMMXieQa are all transitory in character. The history of the case will also
B Msidt us in arriving at a correct judgment.

■ Epilopsy, if seen from the beginning of the paroxysm, cannot be

■ mistaken for cerebral hemorrhage, nor this latter for epilepsy, if the

■ onset of the attack has been witnessed. Even if there are convulsions
I present in the apoplectic seizure, the error could not readily be oom-
^^^L ^pitted if attention be paid to the attendant phenomena. For there is
^p%0 biting of the tongue, the convulsions are persistent, and the animal

beat ia lowered, wliereas in epilepsy tho temperature rises at once and
remains high — 105^ Fahr. or thereabouts, during the convulsive stage,
But the person found in a comatose condition, with no previous history
to gttido us, may be supposed to be either in the comatose stage of an
eptleptio paroxysm, or to be laboring under a seizure due to extravasa-
tioci of blood. In such a case, if the At has been epOeptie, foam will
t bo foitnd around the mouth, and perhaps blood fncim injury of the

■ loilgii9 or cheek. Moreover, the stupor of epilepsy is not usually of long
durafioii, and is not generally cliaractorized by stertorous breathing.

In un^mia, tho coma of which is very similiir to that resulting from
ebral hiemorrhttge, the history of the case is our chief reliance for a
"correct diagnosis, though the absence of hemiplegia and the general
presence of anasarca are of course of great value. Moreover, in very
doubtful eases the urine may be drawn off by the catheter, and exam-
tin*ii for albumen and tube-casts. If these are present, the probabiUty
of ttc stupor being due to Brigbt's disease and ura*mic intoxication is
Hwwf much incTi?ast'd. The fact, also, that in uncroia there is a pro-
gnamve fail of the uninud temperature^ — as low as *JL5' Fahr, being
ro^etiod — and that there is no subsequent elevation, are important
polnt9 In this connection.

Coma is SKJUietimes a manifestation of hysteria, but a very little

inaintance with the phenomena of this condition will suffice to pre-

iktakes. In some cases of hysterical coma there is well-markeil

'fcttnlpleffla; but even when this complication is present, the facts that

tbe bysCerical diathesis exists, that there have probably been other mani-

^ foititin>DS of liystcria, that the pulse is small, weak, and frequent, and

H tlal tbe breathing is free from stertor, will enable a correct diagnosis

H to bo foftoad.

■ In narcotiitm the condition often bears a close resemblance to that
iw6 to oerebral hiemorrhage. But in the former there is no hemiplegia,
tbm pcipils are generally coutracted, the respiration is not stertorous,
and tbc coma comes on gradually.

HI DISEASES OF THE BRAIX.

I )ninkniinoAM and corohral hflemorrhage are often confounded. I have
known mime Mad mlHtakoH of the kind to be made, both by professional
and nr)n-prof(¥KHional ])onon»j many of which were unavoidable, for it
nniNt bn confcflMcd that tlierc are great difficulties connected with the
Nubj(*(!t. The habit of drhiking alcoholic liquors is so general that no
n'lianr.(^ can bo placed upon the test of smelling the breath. A person
may have jitnt taken a glass of wine or of brandy, and be seized with
cxtravaHation of blood in his brain immediately afterward, and when not
in tlio loast intoxicated. And, even if dead-drunk, he may at the same
tiinr have cerebral haemorrhage. In such a case as the latter, discrimi-
nation would be impossible. In ordinary cases of alcoholic intoxication
the ]>atient can generally be roused to some extent; the pupils are
<liIatod, but this latter is often the case in haemorrhage; the breathing
is usually free from stertor, but some drunkards always snore; the pulse
if* small and weak, and there is no hemiplegia. When all these symptoms
are in aocortl, there will be little difficulty; when they are not, the
l^hysioian must be guanled in his expressions of opinion, and diligently
in<iuin« into the personal characteristics of the patient and all matters
bonring on the history of the case.

From the centric diseases previously mentioned, the diagnosis cf
corobral haemorrhage is easy as regards some, and difficult as to others.
Thus, from embolism it cannot in many cases be distinguished in the
first stage. Dut when all the phenomena are taken into consideration
the chance of error is very much diminished. Embolism is generally
aooom]>aniod with disease of the left side of the heart, and there is often
a history of rheumatism ; there are never any premonitory head-symp-
toms ; it i>ccurs in young persons as well as old ; for reasons which will
bo explained when the subject of partial cerebral anaemia from embolism
is cv^nsidonHl, the resulting hemiplegia is generally on the right side ;
the j>aralysis giMiorally disappears in a few hours after the attack ; if it
dvv>s not, there is no gradual improvement, as in cerebral haemorrhage ;
thon^ are no contniotions or partial convulsions,' and there is more fre-
queiuly delirium.

Tlie in^dual development of the symptoms in thrombosis, tumor or
absoosss and the fnHjuenoy with which convulsions ensue in the latter
diseast^s* to^nhor with the associated symptoms, will prevent the ooma
which SvMuctinics exists being mistaken for the stupor of cerebral hiem-
orrhairt\

Ouring the subset|uent stagw of cerebral haemorrhage, when the
mental <N^ndition and the hemiplegia are the most prominent features,
inqxiiiy into the anteo^Hicnt history will bring out the foregoing poiats,
and assist us in arrivinir «t a correct idea of the cause. Even, however,

• .Uv\v>u.i (»Y^ Si„ IX UV ^^^ ASM-r». ibo«gb I hAv« seen cue caw in wbiehpoi^
itor:*^r.-. cvarr-iritn.-*: Twwiit^i she prrt»«s» of «& eabolw in the middle cerebral •xterj,

CEREBRAL H^MORRIUGE.

we be baffled in this respect, no great inconvenience could result
iitber to the patient or physician.

Ptt^osis. — The prognosis depends upon the extent or situation of
he hieinorrhage, and refers to the probabiHty of sa^^ng Ufe during- the
eriod of attack and immediately afterward, and of curing or mitigating
r subsequent paralysis.

In the severe apoplectic form, death is almost inevitable; so far as

my experience goes, it is the invariable result* It generally takes place

riihiii a few hours. If^ however, life be prolonged till the fourth day,

bere is some hope. Irregularity of pulse, or one very rapid, iuiposbi-

bility of swallowing, involuntary evacuation of the fiBcea, and cold

sweaty render, if possible, the prognosis still more unfavorable.

In the apoplectic fonn attended with paralysis, the gradual increase

the coma and hemiplegia indicate the continuance of the hfemor-

e, and are consequently of grave importance. About one-third of

attacked with this form die. The prognosis is bad in proportion

ike debility and age of the patient, and the circumstances under

irliicli tbe attack has occurred* Thus, if it has supervened in a person

who has had no obvious exciting cause, the probability is that thei-e is

<fleriou8 disease of the blotKl- vessels, whereas, coming on in a young per-

ma the result of severe muscular exercise, or mental strain, the i>rog-

mms la more favorable. A second attack is more apt to prove fatal

than a first, and a third than a second, and so on.

Ill the mild fonn characterized by paralysis, but no loss of conscious-

the prognosis is generally favorable. It must be xecollected, how-

r©r, that the risk of inflammation is quite great, both in this and tho

[}p{ectic form with paralysis, and that the patient is not safe from it

'till after the eighth day.

And in both forms, if the temperature rise above 100^ Fahr. ; if tho
respiimtion be chiefly abdonunal; if the patient is unable to swallow;
and mltling of mucus is heard in the throat, the prospect of recovery is
bad* Tbe same may be said of pain in the liead and coo tractions of the
paimljsod muscles. If, further, as Bourneville has shown, the t6mj>era-
ture peaches 104^ Fahr., death is inevitable.

As regards the probabiUty of recovery from the paralysis, much de-
pefMl> f«o opportunities the patient may have for receiving proper

Hkcdt' uient. The tendency is generally toward amendment even

in til© worst coses. Gradually the speech improves, the breathing be-
CDmes better, and the arm acquires more strength; but the improve-
ment often irtops here, and never goes on unaided to complete recovery.
Tli€» longer thi> paralysis has lasted, the less prospect there is of great

IprugTCiss under any treatment; and, if strong contractions producing
distortiona have taken place, the prognosis is unfavorable.
Gortain muscles reoover better than others. The extensors of the

86 DISEASES OF THE BRAIN.

foot and hand are especially intractable, but, as a rule, those of the
lower extremity improve more rapidly than those of the upper.

The mind ordinarily improves, pari passu with the physical symp-
toms, though not always. I have witnessed several exceptions to the
rule. Even in slight cases the intellect may suffer to a great extent,
and in no case is it ever in all respects as good as before the attack.
Among the unfavorable signs are, persistent irritability of temper, fail-
ure of memory, and the existence of delusions. Difficulties of speech,
whether as regards the memory of words, or the ability to coOixlinate
the muscles of speech, so as to pronounce them properly, are often very
persistent. I have now under my care a gentleman who was attacked
with cerebral haemorrhage two years ago, whose physical powers are
quite good, and whose mind is not seriously impaired, but who cannot
yet remember sufficient words to carry on an ordinary conversation.
"When the difficulty is simply due to paralysis of the tongue and facial
muscles, the prognosis is more favorable.

Morbid Anatomy. — ^The seat of the extravasation from cerebral haem-
orrhage may be in the substance of the cerebral tissue, or in the ven-
tricles. The former is much the more common.

Now, the blood, which is poured out from a ruptured vessel into the
substance of the brain must, of course, occupy its place by separating
or lacerating the fibres. It thus forms for itself a cavity, which en-
larges as the haemorrhage goes on, until at last the resistance to further
separation or laceration may be so great as to overcome the tension of
the blood, and thus put a stop to the bleeding.

The shape of the cavity varies according to the manner by which it
has been produced. When it is formed by the separation of the cere-
bral fibres, it is generally elongated ; whereas, when produced by lacera-
tion, it is oval, round, or irregular in form. The situation of the hem-
orrhage modifies the form of the cavity. In the hemisphere it is usually
round; in the motor tract, irregular or oval. The variations as regards
size are great. I have seen clots no larger than a pea, and again as
large as an orange. When haemorrhage occurs in the motor tract, the
clot is almost invariably small; whereas, in the hemispheres, in the cere-
bellum, or in the ventricles, it is large.

A clot does not always consist of blood alone. Brain-tissue is very
often mixed with it, and this is especially the case when the extravasa-
tion has been into the white substance of the hemispheres.

Grintrac * has collected the data of five hundred and sixty cases of
cerebral haemorrhage, in which there was a single clot, and in these the
seat of the extravasation is shown in the following table :

* " Traite th6orique et pratique dea maladies do I'apRareil nenreux '* Tome deujudmflu
Paris, 1869. Art ** H^morrhagies du cerveau."

CEREBRAL H-EMORRHAGR 87

yt^^ - '-'' • ^«

tetad. . »3

ODipOfm strUtA hqiI o|iiic tUalftiu! Btroultimcoualj .....* 48

Mldille )obe« of the brftm. 137

l\ma VaroUi uid cnirn cerebri * * . . . . 7fl

CcrDt)elliLm * . . . . ....... &5

Teotricici • .40

Popterior lob^ of tbe bmio . 33

Anterior lobes of the brain. 17

McduUa oblongitft. 2

CSorpu^ caUo0um 1

Conkal eubstonce of the brain * 46

Total 660

The ordinftty ae&t of cerebral h^morrliage is thus seen to be the
motor tract, for in nearly one-half of the total number of cases the
Imon was situated either in the corpora striata, the optic thalaini, the
pons Varolii, the crura cerebri, or the medulla oblongata. And of these
parit the corpora striata and optic thalanii are preiJimnentljr liable.
Kext in order of frequency come the middle lobes.

In the great majority of the cases of cerebral heemorrhage the lesion
is sttimtcd primarily in the gray substance. This is probably due to
the fact of the greater vascularity which this tissue possesses* It
appear, toOj that even when the extravasation is not into the
striatum or optic thalamus, it is very apt to be in the immediate
wiuity of these organs, M. Buret ^ has given an anatomical expla-
oation of tlus fact, which appeai-s to be satisfactory. According to this
ob^crver^ the arteries of the corpus striutum, which are given off gen-
erslly from the middle cerebral artery, though sometimes from the
mnteiinr cerebral^ enter the brain through the anterior perforated space.
A few delicate branches go to the veutricukr ganglion of the eorpus
striatisiii, but the larger ramifications are distributed sometimes to the
ipxtemal nucleus of the eorpus striatum, but more generally they wind
sroojM] this organ, and give origin to branches which are widely dis-
tlibiitddy roJU^hing even as far as the island of RelL Thus the largest
intiS^iOorobrml arteries are situated in the external portion of the corpus
stmtmn. And tiiis h the exact plaoe where, according to Charcot,
oembtml hasmoirhage is most apt to occur.

Qendm * bad previously remarked that the extravasation in C4»es
of ee^rebnd bm^tnorrhage almost always come from the branches of the
middle cerebral artery. The middle lobe, the island of Reil, the corpus
ftrislum, and the optic thalamus, are nourished through this vessel, and
koieo the gr^t preponderance of extravasation in these portions of the
eaoepliallo mass.

•"Firte ittr la diiitribuljon dcaartdres nouTricJ^res da eerveaiL*' Moftvfmmi mi^
te78» p. 27* Abo, " Bcchercbes nntttaiuiques aur la circulation de I'eiicdpbale.** <
dtpkytioh^, 1874, p. BU,
• •*Trm*li |4iIoiopbUiQe de m4decine pratiqae." Parle, 1888, lonie i., p. 448.

88 DISEASES OF TRE BRAIX.

It has also been observed — ^and Durand-Fardel ' calls special atten-
tion to the circumstance — that cerebral hsemorrhage has a manifest ten-
dency to be developed and directed, rather toward the central than the
peripheral parts of the brain. It is thus, to say, centripetal in its course,
in which respect it differs from cerebral softening, which is not less
evidently centrifugal — ^the peripheral regions showing a greater ten-
dency than the central to be affected by this morbid process.

The right side of the brain appears to be more frequently the seat of
cerebral hsemorrhage than the left. Thus, on consulting Gintrac," we
find that in three hundred and sixty-nine cases in which the side on
which the lesion was situated was noted, the parts were affected in
the order of frequency shown in the following table :

• Kiffht Left.

Corpus striatum, optic thalamus, and these bodies simultaneously 73 63

Middle lobes 63 62

Pons Varolii 10 10

Cerebellum 14 12

Cortical substance 16 8

Posterior lobes 18 16

Anterior lobes 6 10

Total 199 170

The right side had thus a numerical superiority of twenty-nine over
the left. It will be observed, also, that in no one part did the left side
predominate except in the case of the anterior lobe. On the other hand,
Durand-Fardel,* from an examination of one hundred and seventeen
cases of hapmorrhage into the hemispheres, found that the right side was
the seat in forty-nine, the left in fifty-seven, and both sides in eleven in-
stances. Of eleven cases of cerebellar hsemorrhage, the right lobe was
affected six, the left five times, and the middle lobe twice.

Generally there is but one recent extravasation, but occasionally two
or more occur simultaneously, or at least so near to each other in point
of time as to be essentially contemporaneous acts of one morbid pro-
cess. Of one hundred and thirty-nine cases cited by Durand-Fardel,*
twenty-one were multiple ; eighteen of these were double, and three
triple. In my own experience two cases of triple lesions have occurred,
and two of double lesions. Of the triple cases the right corpus stria-
tum, right middle lobe, and left middle lobe, were the seats in one, and
the right and left corpora striata, and left anterior lobe, in the other.
Of the double cases the scats in one were the right corpus striatum,
and right middle lobe, and in the other the right middle and posterior
lobe and right half of the pons Varolii.

It s6metimes happens that the mass of extra vasated blood breaks
tlirough the cortical substance of the brain, and appears immediately

* **Trait6 pratique des maladies des vieillards/* Paris, 1878, p. 181
^ Op. H loe, cit, ^ Op cit, p. 186. * Ojy dt, p. 186.

CEREBRAL H-EMORRUAGE.

er the pia mater and arachnoid; or these membranes may g-ive way,
the bloocl be eHused iiito the space between them and the dura
Ottter. In & very few of these cases the blood comes primarily from
the cortical substance of the brain^ but in the greater number the ex-
travnsation originates more doeply anil reaches the surface by lacer-
mt'mg the easily -torn white tissue, llie blood in these cases undergoes
ooagulation much more rapidly than when it remains in the cerebral
lubfftance, unless the base of the brain be the seat, in which case it often
remains fluid.

The extravasation takes place into the ventricles in about one-half
of aU the cases. The lateral or fourth ventricle may be the seat, or
tl mJiy exist in both of the former. The blood extravasated into the
Tentricles remains liquid a longer time than when effused ijito any
other part. This is probably due to the fact that it b subjected to the
iciioQ of the ventricular lluid, by which its physical properties are
alten«cL

In the majority of cases of hiemorrhage into the ventricles, the
blood comes originally from the corpus striatum, or optio thalamus,
but it may also be derived from the choroid plexus, from the septum
luctdum, or from the walla of the ventricles. Sometimes it is im-
pose^ible to determine its point of origin. It may enter the ventricle
through a small opening, in which case the foyer is distinct, or the
wall of the ventricle may be largely lacerated and so broken down that
ih^ foyer and the ventricle constitute essentially but one cavity. The
neptum lueidum is not infrequently torn, and the two lateral ventrictei
are thus converted into one cavity.

A» rt^g&rds what may be called the secondary oonsequence^ of an
extravaitttion of bloo<l into the cerobral substances, we find that when
H ia large the convolutions are flattened against the walls of the cranium,
the membranes are usually dry, and a diistinct feeling of fluctuation can
oftvn be detected. In several ca«es I have known a large extravasation
to cattle by its own weight a complete rupture of the lobe in which it
iixiated, through the handling required in removing the brain from the

other times the membranes are evidently congest^; the brain-
, when incised, exhibits an increased number of red points, and the
Didean or ventricular liquid may be largely augmt'oted over
tlie nomud quantity.

Th» r the artcrirs is a most important and interesting st abject

Ibr rX't s but, as it has un inmiediate and direct relation with

the pathogeny of cerebriil haemorrhage, it will be more properly consid-
aifd under the hea<l of pathology.

Extravasated blood undergoes certain changes. Insteail of di-
Yidloi^ into two parts, the clot and the serum, as docs blood when
#s|M»ed to the atmosphere, it remains for a time homogeneous and

DISEASES OF THE BEAIK.

gelatii^iform* About tlie fifth or sixth day it separates into two pa
the one, the serum, is absorbed by the smrouudiDg tissue; the other,
consisting mainly of the hbrine and the red corpuscles, contracts and
becomes hard, By the fiiteenth day it has become fibrinous in texture,
and is changed from its former black hue to a yellow color. Micro- I
scopic examination, made at any period during these changes, reveals
the presence of red corpuscles, crystals of heraatoidin and sometimes
cholestrin. It never entirely disappears.

In the earlier period of the extravasation, the walls of the cavSJF
are rougli, and discolored with blood. But^ as the changes are going
on in the clot, the walls likewise alter in appearance ; the inequalities
and irregidarities disappear, and a new formation of connective tissue
lines the cavity. Blood-vessels appear in it, and aid in the absorption
of the fluid portion of the cxtravasated blood. As the process of
separation and absorption goes on, the cavity contracts upon its con-
tents, and eventually forms a cicatrix which incloses the remains of
the clot. This cicatrix is generally of a yellow color, and iirm in
texture.

Sometimes, however, absorption does not take place. The con-
traction of the walls of the cavity does not therefore ensue, and it
remains distended with raore or less altered blood. This may be the
start ing*puint of secondary lesions^ or a new hj^morrhage may oocmrj
into the same cavity, or an abscess may result.

Pathology, — The theory of cerebral hfemorrhage brings us to the |
consideration of several important points. One of the first questions to |
be solved is, Can the rupture of a vessel of the brain take place — not in- i
eluding traumatic causes — unless the vessel is in a diseased condition t J
Both sides of this proposition have their adherents. On the one part^
it is urged that cerebral hivmorrhage never takes place spontaneously
unless the walls of the bleeding vessel have been so injured by disease
as to destroy their strength and elasticity; on the other, that it is per*
fectly possible- for a blood-vessel to give way, owing to the increased
tension of the blood or disease of the perivascular tissue, without the
%vaUs of the vessel itself being in the least diseased. \Yhile admitting
that, in the majority of cases, the structure of the yielding vessel will ]
be fourvd to be impaired, I am satisfied that either of the other two
causes may produce a rupture. The reasons for this opinion will be ap-
parent in the course of the following remarks.

One of the most common diseases to which the cerebral arteries are
liable is, chronic endarteritis, a condition which has been well described
by Yirchow,* and which is particularly apt to be met with in those who,
from age or other debilitating influence, have had their nutrition im-
paired. As the consequence of this state, the vessels lose their elas-

' *' Ufbof die Erweitcruop kk'inererGcTasse/' " Archir fur Path, AoJit. und Phriiol.,"
, m., 1848, and ** Ccllukr-pathologie," Berlin, 1871, S. 458, tt atq.

CEREBRAL HEMORRHAGE.

bcKJome brittle, and are therefore often unable to bear the ordi-
nary tension of the blood, much less any severe strain. This disease
may terminate in fatty degeneration of the arterial walla, or this last
oonditiou may be the primary affection. Fatty degeneration, like
«^iroujc endarteritis, is most commonly mot with in badly-nourished per-
sons, but who are at the same time cachectic. The inner coat is the
point of origin, and hence it sometimes happens that this and the mid-
dlo ooat give way, leaving the external coat entire, and thus forming an
Mienrism* But Bouchard,* who has examined into this matter with
gremt minuteness, denies that such aneurisms are ever found, and as-
wetts that the so-called aneurismal sac consists of the lymphatic mem*
bmtie, lining the cavity in the perivascular tissue, through which the
vnssel passes; and that the blood, in such cases, has already ruptured
the vcssolp In reality, however, there is no hnemorrhage into the cere-
bral tissue till thb membrane gives way.

In a subsequent niemoir, by MM. Charcot and Bouchard,' this point
b attU more thoroughly considered, and the opinion expressed that cere-
bnd hsemorrhage is almost invariably duo to what they call mUiary
WUmawam^ which are the residt of arteritis, and which are not neces-
aftrilr preceded by atheroma*

The existence of these minute aneurisms was first pointed out by
Oreirettbief,' and was subsequently recognized by Calmeil,* Meynert *
appeam also to have noticed tliem, and Heschel * discovered them in the
pons Varolii; but no one previous to Charcot and Bouchard culled at-
tention to the relation which they bear to cerebral hiijmorrhage. On
Sfafeh 1(J, 1866, 'while examining the foyer of a recent extravasation
ixito tlie brain, they perceived, on the walls of the cavity iii the cerebral
taflue, two small gloliular masses attached to a minute vessel. These
urere ntiliary aneurisms. One was rupture<l, and its contents were in
tmractliate relation with the mass of extravasated blood constituting the
apopkctlc clot. Previously to this time these observers had noticed
ttietfe a&6iirtsnia, but not before had they associated them with the
ptttfaogeny of cerebral haemorrhage; since then, in numerous communi-
Cfttfonsii tlicy have called attention to the importance of their discovery,
mod ila value is generally acknowledged by neuro-pathologists. In the

f f)iif(lqttc:i poinici cJe U pftthog6me des h^morrhiigief cirdbmles/* P«ri«,

' **|loiiT<iUat r^cbcrehes cur U pathog^nie de rti^morrhtgD c^r^brale/
fikl^^mrmak rt pntholoffique, \m%, pp. 110-643.

• ** Anaioinii pAlholopciuo da corps humain," lb. ixxuK» PL 2, Fig, 3.

^ *'lMft4 dca m*U«1i*.^ infljimraiitoires (hi cerwau/' Paris, 1859, tome ii, p, 52S.

• '*IJ«b«r Gofwti^t-rjtiirUinjjeii in der YflrobbrQL'ke and dea Gehimschenkelm.** AU^
«MM# Wkm^ MVAmM-Ari/V/Xo. 28, 1864.

• "* Dto <^pm»r-Atit'ur\?jiii^!Q im Pons VAfolii,*' Wiiner Medici nixehf Wochen$ckrifl^

CEREBRAL HEMORRHAGE.

tnata, and in the white subatance of botli hemispheres; a large
extrnvasAiion had also taken place into the right hemisphe'rc.

In sixty-nine cases of cerebral haemorrhage in which post-mortem
^ enamlBations were made, atheroma was found but in fifteen, or twenty-
H two per cent., while these miliar}' aneurisms were met with in every
^HMigp They appear as little globular masses in the small intracranial
J^HBHUi and are in size from one-tenth of a millimetre to one millimetre*
If they contain liquid blood, they are redj but, if the blood be coagu-
lated, the color is dark, almost black in some cases. In the order of
frequency, they are found in the optic thalami, the corpora striata, the
I coovolations, the tuber annulare, the cerebellum, the centrum ovale, the
' CFQm cerebri, and the medulla oblongata.

According to Charcot and Bouchard, the arteritis, which results in
tiie formation of these aneurisms, is diffuse in character. It is found
not only in the minute artery, w^hich is the subject of the aneurismal
dilatation, but extends to the entire system of minute intracranial ves-
sels.. This arteritis is in some respects analogous with what Kokttansky
described under the name of chronic peri-arteritis, and is characterized
by disease of the membrane, designated by Robin as the perivascular
ibaaith, and by His as the lymphatic sheath. There are also lesions of
the adveotitiouB tunic and of the muscular and internal coats. The dis-
eased action proceetJa from without inward, and hence the name of peri-
arteritts is a very proper one.

Ouireot and Bouchard claim that, with tbe following exceptions, all
OMes of ocrebral hicmorrha^e are the result of the rupture of miliary
metniHfnn, viz*, fracture with depression; the hiemorrhages which result
from tkoRiboais of the sinuses, and those which occur in the course of
depraved states of the system. While admitting that the ma-
ty of cases of cerebral huinorrhage have this origin, I ani not pre-
pared to go so far as tliese observers in ascribing all not embraced in
the three categories of exceptions above specified, as being due to this
I had recently the opportunity of convincing myself that this
explanatiun of the pathogeny of cerebral haemorrhage is too absolute j
for, OQ ex;&mining the brain of a patient who had died from an extra va-
[cKtioo of blood into the left corpus striatum, optic thalamus, and left
tventricle, not a single miliary aneurism could be discovered, al-
they were carefully sought for in all parts of the brain. The
pftiiettt^ a IsHy forty-three years of age, had suffered from repeated
AttAclcai of acute rheumatism, had frequently been affected wuth head-
iche and vertigo, and had been seized with apoplexy while in tlie water-
dosH. She had been the subject of heart-disease for over twenty years,
I hmd only the brain submitted to me for examination, but all the ar^
f leiies of this organ were in a state of atheromatous degeneration, and I
to find what appearetl to be the vessel, or one of them, which
Sftd produced the extravasation. The accompanWng

94 DISEASES OF THE BRAIN.

engraving (Fig. 12) represents this artery as seen with an inch-objec-
tive. It is perceived that several of the aneurismal dilatations have
given way; ther internal coat of this, as well as of other arteries, was

Fig. 12.

found, by microscopical examination, to be in a state of fatty degen-
eration; the same state existed in the middle coat, and the external
coat was thickened and friable.

Lancereaux * reports a very similar case, of which, as it has an im-
portant bearing on the subject, I quote the summary which he gives
(page 424) :

" Haemorrhage into the left " [right is evidently meant, and it is so
stated on page 252, where the full report of the case is given] " corpus
striatum, producing an irruption into the lateral ventricles, and arteritis,
albuminuria, cardiac hypertrophy.

" A woman, aged fifty-eight, died a few days after an attack charac-
terized by left hemiplegia, diminution of sensibility, and vomiting. The
autopsy revealed the existence of a haemorrhagic clot at the exterior
and posterior part of the corpus striatum, which, *after having separated
this ganglion from the optic thalamus, had broken into the ventricular
cavity. The nervous tissue, besides being torn, was colored yellow,
through the infiltration of lurmatinc into its substance. The ventricles
contained a small quantity of liquid blood. There existed under the
epend}Tna of the posterior cornu of the right ventricle a haemorrhagic
punctation, and a sanguineous suffusion extended over the whole cir-
cumference of the cerebellum. The entire encephalic mass was injected.
The walls of the cerebral arteries were thick and opaque. On the
branches, even those of the smallest size, were perceived moniliferous
dilatations, the result of a primitive alteration of the arterial wall, and
the probable points of origin of the haemorrhage. The aorta was af-
fected with endarteritis throughout its whole extent, the aortic orifice
was slightly insufficient, and the left ventricle was markedly hyper-
trophied ; the renal arteries were indurated, rigid, and calcareous. The

* '' Anatomie pathologiquc,'* texte, pp. 252 and 424 ; atlas, plates 24 and 48.

CEREBRAL ILEMORRIUOE.

kUbeys, small, atrophied, and granular, were affected with interstitial
aephrittSk The arterial system was involved throughout almost its en-
tire extent,"

It would appear, therefore, that we cannot set aside the results ob-
tained by Yirehow and others, and that, in the present state of our
knowl«»dge, it is safe to adopt the opinion expressed by Durand-Fanlel,'
that, although " the facts observed as descTibed by 3IM, Charcot and
Bouchanl have undoubted value, it would, nevertheless, be premature
to attribute to miliar^' aneurisms an exclusive part in the production of
cerebral hiemorrhage."

The condition of the perivascular tissue, or the brain-substance, has
much to do with the occurrence of hiemorrhage. One reason why ex-
travasation more frequently occurs in the brain than in the liver, for
instaiice, is, that its tissue is softer, and therefore not capable of giving
IS much support to the blood-vessels as is the latter organ. Now, when
llie cerebral substance is softened by disease in any part, the natural
iupport of the vessels of that part is still further lessened, and the ten-
dency to hemorrhage increased. Again, in tlie condition sometimes
mrt- with in old people, in which the brain becomes atrophietl, the ves-
iCib may undergo dilatation and subsequent rupture. This view is op-
pcwsd by Jaocoud,' but in one case of cerebral i Hemorrhage, terminating
fat deaths and in winch I had the opportunity of making a post-mortem
esmiiiiation, the right hemisphere, the seat of the extravasation, was
very ooDsidcnibly atrophied, and w^eighed three ounces and a quarter
hsm ihrnn the left. The possibility of the existence of this cause may,
tbefefore, be adtnitteilj although it carmot be considered as definitely

.blished« The researches of Cotard ' would appear to show that cere- '
luBHiorrliag^ is not infrequently a cause of partial atrophy of the
bimin.

In tbe next place, the state of the blood, as regards quality and
leodiofiy must be con&idered. There can be no doubt that certain dis-
Hjlinfl aflcctiog the general system may so deteriorate the blood as to
retldar it unfit to properly nourish tho blood-vessels, and hence their
ttstfoe is more reatlLly broken down. Among these conditions are
tjrphusy scurvy, chlorosis, gout, and syphilis,

Tbo trn*ion of the blocxl in the vessels is subject to constant vari-
ation from the operation of many physical and mental causes, and may,
Ikrovi^ti their action, be so increased as to overcome the resistance
afforded by the vascular walls. Those influences have been sulBeiently
floondened in the section on causes, and need not, therefore, be dwelt
ilpoQ hero At any length. My own opinion of their sufficiency, without
pftSziJilifig disease of the blood-vessels, to produce rupture and ex-
limvsMktiDci, 1ms been formed after much observation and refleotioo.

» Op. A, p, SKS2. • Op. cU., p. Ift5.

• ** italic iur l*iitPophie particllc du ccrve&u," Fails, 18^8.

DISEASES OF THE BRAIN.

Analogous phenomena take place every day, and are not supposed to
be due, in any extent, to vascular disease. Thus nasal hfPmorrhage
occurs from strong muscular exertion of such a character as to retard
the flow of blood from the brain, from emotional or other kind of
mental excitement, and from hypertrophy of the left side of the hearty
by which the amount of blood in tlie cerebral vessels is increased, AH
these causes augment the tension, and it would be singnlar if at times a
healthy intracranial vessel did not give way through their influence, aa
well as one outside of the skull.

A point of very great miportanoe remains to be considered as a part
of the pathology, and that is whether it is possible or not to determine
during life in what part of the brain an extravasation has taken piace?
While I am afraid we cannot be as explicit in this matter as is desirable,
I am very sure we can often, from a careful study of the symptoms,
arrive at conclusions more or less accurate, and can sometimes detex<-
minc the question with absolute certainty. The great difficulty is, that
we are not yet sufficiently acquainted with the physiology of the several
parts of the brain, and hence are not able to ascribe, with as mucli sure-
ness as is desirable, variations from healthy action, to derangement of
the proper anatomical part of the cerebral mass. Besides, when the ex-
travasation is large, although it may be strictly confined to the ana-
tomical limits of the ganglia or part of the encephalic tuiiss in which it
originates, it may act by transmitted pressure upon contiguous ganglia
or parts, and hence the symptoms are rendered complex.

As we have seen, hiemorriiage is more Hable to take place within the
ganglia constituting the motor tract than any other part of the brain*
This is mainly due to the fact that this h the most vascular part of the
cerebral substance.

When the lesion is limited to the corpus striatum of one side, the
speech is generally affected from paralysis of the tongue, and there is
loss of the power of voluntary motion on the opposite side, but nc?
abolition of sensibility, except, perhaps, for a few hours. Cases in
illustration of this fact have been given by Andral ' and Luys,* and one
instance in my own experience was established by post-mortem examina*
tion. The patient, a man of sixty-two years of age, ba<l been hemi-
plegic for eleven years, and died suddenly, in April, 1S51. Post-mortem
examination showed the cause of death to have been fatty degeneration
of the heart. On examining the brain, a cicatrix was discovered in the
right corpus striatum. The hemiplegia was on the left side, and
had never been accompanied with any loss of sensibility. There "waa
no other lesion of the brain, so far as could be ascertained.

But there are instances on record in which there has been extravasa*
tion into the corpus striatum, and no paralysis of any part of the body.

J *' Crmif|iio m^dicale," tome v., pp. 319-821, 442.

* " Hccherclics sur le systemt; nt;rveiix c6r^bro-apinal,'^ etc,, p. 649.

CEREBRAL U^MORRHAGE.

ic»* of forty cases collected bj him, found apparent absence of paral-
ysis ift Eve- But he admits that this number may perhaps be reduced,
for one of the cases was that of an infant one day old^ and the other^
that of an old man eighty years of age, who had had a cerebral hfora-
orrbagie ten years before his death, in both of which an exact diagnosis
of this point could not have been otherwise than difficult. But in one
of the others there was no paralysis, and yet after death a clot as large
aa a pigoon*8 tgg was discovered in the left corpus striatum. In the
second there was no actual paralysis, but a weakness and trembling of
the right arm. The post-mortem examiimtion revealed the existence of a
dot, as large as an aknond, in the left corpus striatum. The third was
for a few moments deprived of the power of speech, but he had equal
raascular strength on both sides. Then he became weak and died,
without having been actually paralyzed. After death a cavity filled
with a brown serous fluid was found in the anterior and external part
of the right corpus striatum, and the whole of the left posterior lobe
waa reduced to a yellowish pulp, and was studded with purulent /^^i/er^.
Tbb was certainly not an uncomplictited case. And thus of the five
tliera vas hut one in which there was indubitably no paralysis.

The optic thalamus is another common seat of extravasation. In
suck a case the observed symptoms are especially connected with the
oigans of the special senses. Thus there are double vision, dilatation or
eoQinil^Te movements of the pupil^ blindness, and anaosthesia or hyper-
aathesia of the paralyzed parts of the body. As in lesion of the corpus
fftriatuni, the paralysis of motion, if present at all, is on the opposite side
of the body. The hearing and smell may also be aJTected. Luys ' has
ooQoeted a large number of cases in support of the view here enun-
ciated,

llie researches of Yircnque ' also go to show that lesions of the optic
thalamus are accompanied with loss of sensibility on the opposite side
of the body. His observations, therefore, are entirely confirmatory of
those of TUrck * who in four very carefully recorded cases found hemi-
aniBstbesia coexistent with lesion of the optic thalamus and corpus stri-
atum of the opposite side.

In those cases of cerebral hremorrhage limited to the optic thalamus,
|>araly«>ts of motion when it exists is less intense than when the corpus
striatnm is also involved, and is often restricted to the inferior limbs.
The »peeeh is rarely involved.

The intelligence is not notably lessened, but there is often a marked
ptodivity to the supervention of hallucinations of the special senses.

* Cp. dl« tome iL, p. 142^ «f ««^. * Op, eit,^ p. 5S4, H aeq*

* De U pertede U flensibilhu g^n6ritk' et spdcialed'un eoto du corjis (hdminnspstheaia)
\ ses relations »toc certaines lesions de« centres opto-stri^s." Park, 18M.
*17«b(Rr die Beziehong gewUsca Krankheitdbenle des grossen Gebir&fl zur Anaes-
SttSangeberichte d(» Kaifl. Kon. Academie der WisaenschafteQ, B. ixxri,, 1869.

DISEASES OF THE BRAIN.

Fio. 18.

This is not surprising when we take into consideration the fact that
recent physiological observations appear to show that the optic thalami
are centres for the special senses. Luys * has very thoroughly worked
up this subject,* and Ritti has recently in a philosophical essay adduced
many facts and arguments to show the relations of lesions of the optic
thalamus with hallucinations. In thirty-two cases of hallucinations,

mainly of the sight and hearing,
but sometimes of all the senses,
post - mortem examinations re-
vealed the existence of some kind
of lesion of the optic thalami.

It generally happens that an
extravasation, originating in ei-
ther the corpus striatum or op-
tic thalamus, involves both these
ganglia. Hence we have, as the
most common symptoms of hsem-
orrhage into these organs, loss or
impairment of the power of mo-
tion, disturbance of sensibility,
dilatation or irregular movements
of the pupil, aberrations of vision
and hearing, etc.

As we have seen, a lesion of
the corpus striatum and optic
thalamus of one side produces
loss of the power of motion and
of sensibility in the opposite side
of the body. The manner in
which this is accomplished will be
readily understood from an in-
spection of the accompanying
diagram (Fig. 13), in which a in-
dicates the left opto-striated body, b the left half of the pons Varolii and
medulla oblongata, c the left lateral half of the spinal cord, d a sensory
nerve-fibre decussating soon after its entrance into the cord, e a motor
nerve-fibre decussating at the lower boundary of the medulla oblongata.
A lesion existing at / will therefore cause paralysis of motion and of
sensibility at (/, on the right side of the body.

When the extravasation beginning in the left optic thalamus or
corpus striatum extends to the fissure of Sylvius so as to involve the
posterior part of the third frontal convolution, ,the island of Reil, or
other part supplied by the middle cerebral artery, or when it originates
in this region, aberrations of speech occur. These are independent of

» 0/). et loc, cit.

* " Throne physiologique de rhallucination." Paris, ISVi.

CEREBRAL HEMORRHAGE.

Fio. 11

sis of the tongue, and are such as are embraced under the term
sift. This subject will be hereafter more fully considered.
Ha?niorrhage into the cms cerebri produces heiiiiplegia of the op-
posite side, more or less extensive, according to the size of the clot,
with loss of sensibility, Tlie third pair arises in part from the ems,
and hence may be paralyzed, producing ptosis and external strabismus
jth© side corresponding to the seat of the lesion, and consequently
site to the hemiplegia.
"VVTieQ the pons Varolii is affected, the crossed paralysis is still more
marked. The limbs are paralyzed on tho opposite side, and the face in
whole or in part on the same side
aa lIuU in which the haemorrhage
I place. If the extravasation is
In the mesial line, both sides of the
puralyxed. According to
iu^' huwever, crossed paral-
ysis is not always due to a lesion
of the pons, as asserteil by Gubler,*
aOfl as supported by additional
J oollected by Luys/ Trousseau
his opinion on one ca«e, in
vhich after death very extensive
I of the brain were found, but
j|5"fclVolving the pons.
Xrvprthcless we find in practice
that when an extravasation of blood
!• confmed to one side of the pona,
ts not extensive, the face is
ilyzed on the corresponding
aide. The fariid nerve makes its
exit from the side of the medulla
oblongata ; some of its niots of
digiii can be tniced as far as the
floor of the fourth ventricle, others
oaam from the lower part of the
lii#dtllla oblongata^ and others de-
9emm\ trom the upper bonier of the
poosi where they probaldy decus-
mt^ Xow, a lesion exi^^ing in a

lateral half of the pons will, therefore, produce a paralysis of the cor-
:»mUtig facial nerve, ami of the opposite spinal nerves; whereas, if it
r above the point of decussation of the encephalic fibres, the paraly-

a, lht» U'fl licmlspluTt'i 6» rijrlil half of iiona', <*.
»tittiAt curf ' '' ''-■>■■' ' -' ' ' * ' rf t>f

of ]>■- 'I of

l^-aod pari »uii|>IUNl tiy »i>liiai nerve.

|tAni-

i cm Clinitfttl Mftlicitif," Bnztrc*i* lmiislfttioi\, Part It, p, X^Z,
• ••Sur Hi^mipl^ Bheme;* (f^x. fuM.^ October, ISruK iinij ** M^moire »iir lea ))am-
" HC, Gm. htbd., 1839. * Op. cit., p, 520, tt t«fy/.

100 DISEASES OF THE BRAIN.

sis will be on the opposite side for all parts of the body. These facts
are shown in the accompanying diagram (Fig. 14).

It is obvious, from a study of this diagram, that a lesion of one lat-
eral half of the pons (at I) will cause paralysis of motion and of sensi-
bility of the opposite side of the body generally, and of the corresponding
side of the face; and that a lesion of the hemisphere (at m) will produce
paralysis of the opposite side of the face and the body.

It is true that it is not definitely settled by histological investigation
that the decussation of the ascending roots takes place, but pathology
is just as capable of determining the question as histology. Vulpian *
asserts that the decussation of the roots of the facial occurs in the
mesial line of the medulla oblongata at the junction of the two nuclei
of origin ; but, if this were the case, a lesion of one side of the pons
would necessarily be followed by double facial paralysis, a sequence
which does not in reality ensue.

From the contiguity of the pons to the medulla oblongata, an ex-
travasation of blood into it is generally accompanied by the symptoms
which result from haemorrhage into this latter organ, though they are
not as a rule so strongly marked.

The principal phenomena indicating the medulla oblongata as the
seat of extravasation are, loss of the power of swallowing, from paral-
ysis of the glosso-pharyngeal, difficulty of protruding the tongue, from
paralysis of the hypoglossal, and huskiness of the voice, tumultuous
action of the heart, dyspnoea and gastric derangements, from paralysis
of the pneumogastric nerve. There is in addition paralysis of one or
both sides of the body.

An extravasation into the cortical substance of the cerebrum is char-
acterized by no very definite aggregation of symptoms. There may be
delirium, coma, disorders of speech, convulsions, paralysis, contractions
or rigidity of either the paralyzed or sound limbs, vomiting, derange-
ment of respiration, and occasionally anaesthesia or hypersesthesia. Pa-
ralysis when present is upon the opposite side of the body from that of
the lesion.

When the extravasation is in the white substance of the cerebrum,
there may be no marked symptoms of diagnostic value. I have known
cases in which large foyers have been formed with no other symptoms
than intense pain in the head and persistent vomiting. But when blood
is extravasated into the white tissue the quantity is ordinarily great,
and as a consequence there are often symptoms present which are due
to resultant pressure upon other portions of the encephalic mass.
Thus there may be coma, paralysis, loss of sensibility, stertorous res-
piration, and other phenomena indicating derangement of the motor
and sensory ganglia. The passage of the extravasated blood into the

' " Essai BUT rorigine de plusieurs pairs de nerfs craniens. Thdse de Paris,^ 1858,
p. 82.

CEREBRAL H.EMORREAGE.

101

rides almost invariably causes contractions or convulsions ol the
BS of the opposite side of the body*

Tlie researches I have made * rektive to the functions of the cerebel-
lum would seem to show that its office is not materially diili^ront from
tliat of the cerebrum. Still, I think there are some indications which,
lihough not perhaps g'lving na the right to form a definite conclusion,

yet sufficiently well marked to enable us to arrive at a probable
dUgoosis between hiemorrbag^ic lesion of the cerebrum and that of the
oorobellum. Thus, vertigo is almost an invariable accompaniment of
ibe oerebellar extravasation; vomiting is much more generally met with
Ihan when the cerebrum ia affected; hemiplegia is not so common; the
aecudbility U never disturbed; and the pain is in the back of the head.

Ferrier ' has very clearly shown that irritation of the cerebellum pro-
dtices nystagmus and defective power of ocular coordination. But I am
QOt aware that these phenomena have been noticed in cases of cerebel*
lar haemorrhage. Hillairet,' in his excellent memoir, does not mention
ibem as features of the aiTection. He distiuguLshes two forms of this
lenan. In the one, the onset is sudden, and death soon follows; in the
ather, the course of the affection is slow, and life may be prolonged for
a considerable period* In this latter, vomiting is a prominent feature*
Hemipleg^, according to him, is always crossed. Sensibility remains
unaifected till near the close of the disease by death, and there are no
ooaTtthions. Tlie speech ia not often affected. The special senses he
did not find notably deranged, except in the last stage. In this result
he differs with several other writers on the subject.

Beddes a number of caaes, some of which are referred to in the

aoira cited, one has occurred in my experience, in which I had the
^fpportmuty of making a post-mortem examination,*

A man had suffertjd from vertigo, occasional convulsions, attacks of
luutsesa, and vomiting, and a constant and violent pain affecting the
h^ck of the head. The symptoms had ensued in consequence of a se*
vera blow wliioh he had received on the back of the head, by raising
litoiaelf ttX) soon while the horse he was ridmg was passing tmder a
few ftTcfaway,

"WTr'O lliis man attempted to walk, he reeled and staggered as if he
! dmnk, Tlie upper extremities and the organs of speech were not
i, be had the entire control of his legs whon lying down, and
was no diminution of sensibility anywhere. At last, he became

wfAcgicy and shortly afterward died in a convulsion. The post-mor-

' **T%e PhysiolapT mid Pathology of the Cerebellum," Quarterly Journal «^iVyMo»
kfkidJMitmt, April, Um.

* **Ex|>eHiiieDUl Researches in Cerebral PliTsiologj «Dd Futhology.'* ** West Ritllag
Idiaiflff JkMjlum K<9|>orti»;' vol. iiL« 187a. p. 69, eiJteq.

^ * Qteorrbai^ e^r£beUeu»e," Annuttire di mM^cim H ^n^r^ie prati^nfft*^ 1869, p,
it. Abo ArM^rn dt mhUdne, 6d. ' Qp^ «j^, p. S09.

102 DISEASES OF THE BRAIN.

tern examination showed the existence of an abscess which had oblit-
erated nearly the whole of the left lobe of the cerebellum. The other
parts of the brain were, ^ far as could be perceived, perfectly healthy.

Besides the occurrence of local secondary lesions, the immediate re-
sults of the presence of a foreign body in the cerebral tissue, there are
others, which are due to the interruption of the normal brain-functions,
which haemorrhage so generally induces. Thus, atrophy of the cerebral
structure may result, as has been pointed out by Cotard * and others, or
the degeneration may extend to the spinal c5rd, as is so well shown by
Bouchard.* In this latter event the process does not begin till about
the end of the fourth or fifth month. It is mainly characterized by the
supervention of permanent contraction of certain of the paralyzed mus-
cles, and will be more appropriately considered under another head.

Another point in connection with cerebral haemorrhage requires
further elaboration. It is well known that the facial paralysis result-
ing from ordinary cerebral haemorrhage is less extensive and less thor-
oughly marked than when it is due to disease or injury of the trunk of
the seventh pair or to lesion of the pons VaroliL Thus we have seen
that, in the former affection, the orbicularis palpebrarum escapes paral-
ysis,' and the other muscles supplied by the facial nerve are usually
not so profoundly paralyzed as when the pons or the nerve is the seat
of the disease.

Many explanations have been oiTered of this remarkable circum-
stance, but the one given by Landry * is more nearly reconcilable with
the anatomy and physiology of the parts involved than any other.

The nucleus of the facial is entirely comparable to the anterior
cornua of the cord. It constitutes a little special motor nerve-centre
which possesses a certain amount of auto;iomy. It is through this
centre that the muscles of the face are directly made to contract.
The encephalic fibres which connect it with the brain are only at the
ser\uce of the psychical department, and an impulse sent through them
is not of itself capable of exciting contraction in the muscles to which
the facial is distributed. But, with the spinal cord, this nucleus pos-
sesses reflex excitability, and, as is the case in diseases of the brain
in which the anterior columns suppress voluntary movements without

' " £tudc 6ur Patrophie particlle du ccn'eau," Paris, 1 868.

• ** Des dc;;ciieratioD8 sccondaires de la moclle epiuiere," Archives gtn. de mSdecine,
1866. Also Hun's translation, American Journal of Insanitif^ 1869.

' Bazirc, in his translation of Trousseau's " Clinical Lectures," calls attention to the
fact that, in ordinary cases of cerebral haemorrhage, the patient, though able to close the
eyo of the affected side, cannot do so without, at the same time, closing the other, a fact
which shows some loss of power. Since my notice was directed to this circumstance, I
have observed that the patient is often sensible of the fact that the eye of the affected
Bide cannot be closed as strongly or as rapidly as the other eye.

* Quoted by Poincar^, " Le9ons sur la physiologie normale et pathologique du syst^me
nerveux," tome deuxieme, Paris, 1874, p. 66.

CEREBRAL ILEHORRBAGE.

103

[c^xv tying Ihe reflex manifest at ioos of which the gray substance of the
rd is susceptible, so the cerebral lesion leaves to the nucleus of the
fjicijtl the power to determine reflex contractions. It therefore con-
tinues to be excited by sensitive eieitatjons which reach it from the
periphery. Thus, in facial hemiplegia of cerebral orif!:in, wo observe,
bom tinie to time, certain movements which appear to be voluntary
beoasLse the provocative sensitive impression, which may only consist of
tl»o contact of air, remains unperceived. Accordingly, the orbicularis
Ipobrarum appears, above all the other muscles, to preserve its mobil-
y, for its movements are principally excited by the stimulus of the
light, which the lesion of the cerebral lobes does not prevent being
ri^dectt'd to the nucleus of the facial. In extensive diseases of the
pons, liowever, the nucleus of the facial, situated as it is, in immediate
I to this organ, is almost always compromised with it. In

8L .. _..se, therefore, both rellex excitability and voluntary power are
d^^troyed^ and the paralysis is complete.

TrOBtment. — ^Tho means of treatment in cerebral hemorrhage are,
fint, those which are applicable to the prodromatic stage, with a- view of
preventing any lesion ; second, those proper during the seizure; and, third,
I hose which are to bo directed against the consequences of an attack*

It oft^n happens that an attack may bo prevented, even where the
Chreatenings are very decided. The condition of the brain is such that
10 indications are to lessen the tension of the blood as much as pos-
Je* Am I have already remarked, under the head of cerebral conges-
tioii« •' itlde^ of potassium and sotiiura are peculiarly efficacious in

accon ^ - this end. lately, in consequence of the investigations

of Dn Sb Weir Mitchell, of Philadelpltia, I have made much use of the
ide of lithium in cerebral congestion with or without a tendency
lueoiORtiage, and have reason to prefer it to either the potai^sium or
flodittm Bait* One feature of its action, which renders it especially use-
ful in audi oases as those now under notice, is the short interval which
ela|>ses between its administration and the effect. I am very sure I
have given it successfully in several cases in which the bromides men*
tioiied would not have acted so happily. In one of these, a gentleman
hvm the South, who had already had an attack, and who was in conse-
^oence licraiplegic, was relieved of his vertigo, headache, numbness, and
lldeieDeae o( speech, by one dose of thirty grains, in less than half an
bottr. The bromide of calcium, a compound to which I have recently
oaDod attention/ is 8tIU more eligible^ It acts more rapidly than any
of the other bromides, and may be given for a longer period with less
detmBgemeni of the organism. The dose is from tifteen to thirty grains,
or aT€tt more, if only a single dose is to be administered. The oxide of
fine may abo be given with advantage.

• Hott rtUttiY to Bromide of Calcium, Xtw York Medicoi Jommai^ Deoombcr» 18TI*

104 DISEASES OF THE BRAIN.

The bowels, if costive, should be opened by a brisk purgative; the
stomach, if overloaded, should be emptied by an emetic, during the
action of which warm water should be freely drunk so as to obviate, as
far as possible, all straining; muscular exertion should be avoided, the
head should be kept cool and well elevated, and the mind in a state of
the utmost tranquillity.

During an attack, and throughout the whole period of reparation of
damages, the less that is done in the vast majority of cases the better.
The question of the propriety of bloodletting will generally even yet
arise, but should in nearly every case be decided in the negative. I aay
nearly, for I know of but one possible fonn of attack in which it can
by any possibility not only not be useful, but fail to do harm; and that
is in a strong, plethoric person, with a full, bounding pulse, in whom,
from the gradual development of the symptoms, we have reason to sus-
pect that the haemorrhage 'is still going on. In such a case, six or eight
ounces of blood may be taken from the arm. But, in the case of cere-
bral haemorrhage, attended by coma and the ordinary symptoms of the
apoplectic condition, there is nothing to be done in the way of medica-
tion which can afford the slightest prospect of relief. It is true, a pa-
tient thus situated may recover if his attack is not of the severest kind,
but it is not through any medicines we give him. Correct views rela-
tive to this point are far from being prevalent, and can only be estab*
ILshed by regard being paid to the morbid anatomy and pathology of
the subject.

A clot in the brain is, to all intents and purposes, a foreign body,
and both it and the walls of the cavity must undergo certain fixed and
definite changes. In order that these changes may go on with the ut-
most possible regularity and certainty, all the powers of the system are
requisite. The processes are not morbid; on the contrary, they are in
the highest degree conservative. To take blood from a body which is
striving by all its agencies to repair an injury, is to deprive it of a por-
tion of its strength without in the slightest degree accelerating the
actions at the seat of the lesion. As Trousseau ' remarks, no physician
ever thinks of bleeding for an extravasation of blood under the skin,
for he knows how perfectly absurd such a practice would be; and yet,
except as regards location, there is no difference between it and the
cerebral clot. A prize-fighter, for instance, receives a blow, in the face,
which ruptures a blood-vessel and gives him a " black eye." He has an
extravasation of blood into the cellular tissue. What would be thought
of the physician who would recommend bloodletting from the arm, with
a view of causing the absorption of the clot ? The prize-fighter has
found out by experience that he can open the skin with a knife, and
let the blood out. The practice is excellent, and would be admirable
for the brain also, were this organ of no more vital importance than the
* " Lectures on Clinical Medicine/' Bazire's translation, Part I., p. 10.

H^fiUORRHAGE.

105

in oi the face. I have never bled a patient for cerebral hictnorrbago
ic€ 1840, and I am very sure that I have had no reaison to regret the
abatidotiineat of the practice.

It is a common practice for purgatives to be given, and even so con-
servative a practitioner as Dr. J. Hughlings Jackson * puts " two drops
of eroton-oil on the tongue," why, he does not state, and certainly the
practice is in direct antagonism not only with his assertion that " the
cMef thiog In to keep the patient quiet^" but with the general tenor of
L' ■ V of treatment. I have seen great annoyance and an aggrava-
i ' snnptoms from the indiscriminate administration of cro ton-oil.
it is only, in my opinion, admissible wlien there is obstinate constipa-
-Hj and when after three or four days the bowels have not been moved.
And then as regards iodide of potassium. There seems to be an
prevalent that this substance exerts a powerful intluence in causing
ttiore rapitl absorption of the extravasatcd blood, and hence it is
Qtly administered in large and frequently*repeated doses. I have
tv patients, at as early a period as possible, while still in a state
uid coma, dosed with the iodide of potassium to the extent of
© grains every hour, with the object of causing the immediate absorp-
'^Hon oi the extra vasated blood. That such a result is impossible no one
acqttamted with the morbid anatomy and the pathology of the subject
will d^uy.

In fact, there is nothing to be done beyond keeping the patient
perfectly quiet, with the head well elevated, and in a room, when
ponibUi, with a temperature of about 60"^ and thoroughly ventilated.
Ipdteatians should bo met as they arise. The bowels, if not moved
oaturaUy every day, may be emptied by an enema of warm water ; the
urina, if not passed by the patient, should be drawn off with the cathe-
ter ; tlia stitmgth, if feeble, as indicated by the pulse, should be kept
yp by the cautious use of stimulants ; and, if the patient is restless and
dees noi sleep well^ some one of the bromides should be administered.
Ergot may, on theoretical grounds, be recommended in those cases
which we have reason to believe that the hrcmorrhage is still going
; but I liave no personal experience of its power in such instances,
II adfuiuiatered, it should be given with no sparing hand*

The food should be of the most nutritious character, so as to be
m quantity, and should be taken frequently, day and night,
Baef-tea, or the extract of beef, made according to Lieljig's fonnula,
mppliea every indication.

U j^rmptoms of intlammation make their appearance, cold appli Ca-
may be made to the scalp, or a blister may be applied to the nape
ibe neck. Blisters or mustard-plasters to the wrist or ankles are

' 8j»tem of Meilictni*,'* vol iL, artiolo " Apoplexy and Cerebral HsBmor-

106 DISEASES OF THE BBAIN.

Nothing should be done for the relief of the paralysb till all signs
of iriitation of the brain have disappeared, and the ^tient Jbegins to
feel the restraint of confinement, and to make efforts to move his par-
alyzed limbs. These evidences of improvement generally begin soon
after the eighth day. In about two weeks, therefore, it will be proper,
in the majority of cases, to take active measures to restore the power
of motion, and to prevent those contractions which tend to make a res-
toration much more diflScult. The agents to be employed are pas-
sive motion, strychnia, phosphorus, and electricity. The first is accom-
plished by flexing and extending the joints of the affected limbs, by
friction, and by kneading the muscles with the fingers. These move-
ments should be performed every day for five or ten minutes at a time.
The patient should likewise be encouraged to move the limbs by his
own volition as often as possible short of causing fatigue. Strychnia
should be given in doses of the one-twenty-fourth of a grain three times
a day, or, preferably, by subcutaneous injection, in somewhat smaller
doses once a day. In old cases of hemiplegia, the effects of strychnia
thus administered are often well marked, and are exhibited when ad-
ministration by the stomach has failed to produce a beneficial result.
This is seen in the following brief abstract of sixteen cases which will
serve as types of numerous others which have occurred in my priyate
practice :

Case I. — H. A., aged fifty ; male ; right hemiplegia. Came tinder
treatment January, 1865; strychnia ineffectual by the stomach; thir-
teen injections, of from one-thirty-second to one-twenty-fourth grain;
much improved.

Case II. — J. S.; forty-two; male; left hemiplegia. February, 1865;
thirteen injections; much improved.

Case IIL-i-S. T.; sixty; female; right hemiplegia. February, 1865;
strychnia ineffectual by the stomach; nine injections; much improyed.

Case IV. — I. S.; sixty; female; right hemiplegia. April, 1865; five
injections; much improved.

Case V. — M. T.; fifty-two; male; right hemiplegia. April, 1865;
strychnia ineffectual by the stomach; eleven injections; cured.

Case VI. — O. S.; sixty-three; female; left hemiplegia. April 30,
1865; secondary contractions; twenty-two injections; no improvement.

Case VII. — ^B. R; forty-seven; male; left hemiplegia. June 11,
1865; strychnia ineffectual by the stomach; seven injections; much
improved.

Case VIII. — R. F.; fifty; male; left hemiplegia. June 17, 1865;
strychnia ineffectual by the stomach; eight injections; cured;

Case IX. — T. W.; forty-eight; male; left hemiplegia. September
5, 18C5; eight injections; much improved.

Case X. — ^1\ S.; forty-nine; male; left hemiplegia. September 7,
1865; secondary contractions; five injections; no improvement.

CEBEBHAL HEMORRHAGE

lOT

L J.; fifty -seven; male; left hemiplegia. September 11,
ly contractions; no improvement.
Ca8B XH, — J, W.; fifty-two; male; right hemiplegia, affecting arm
ilr, at the time treatment was begun, September 27, 1865; strychnia
effect uiil internally; six injections cured.
Case XUL — W, M.; forty-five; male; left hemiplegia. October
li>, 1865; strychnia ineffectual internally; seven injections; cured.

Case XIV* — S, M,; forty-one; male; right hemiplegia. June 17,
1 ^ '^ i\ alone affected; strychnia ineffectual by the stomach; twenty
^ ; cured,
Ca9B XV* — AL C; forty-four; male; right hemiplegia, affecting
le and face only. July 1, 18G7; ten injections; so much improved
be able to talk with fluency.
Cask XVL — ^C. C; Miy; male; right hemiplegia. May 4, 1869;
sliychnm ineffectual by the stomach; thirty-five injections; much ira-
ptoveA

0r. Charles Hunter* has called attention to the advantages to be
ved from the hT>'podermic use of strychnia in hemiplegia; and my
former clinical assistant. Dr. B^ A. Vance,* £as adduced several cases to
Uie tame effect. Instances in support of the views above set forth oc-
dally in my private practice, and nt the Xew York State Hospital
for Diseases of the Nervous System, J have every reason, therefore,
to be convinced of the good results to be derived from the practice.
Pht^phorus administered in the form of phosphide of zinc, separately
in combination w^ith the extract of nux-vomica, according to the for-
mula given on page 54, is also a useful remedy.

Bat no agent is so valuable in hemiplegia as electricity, and amend-
iCDt almost invariably follows its use, even in old cases, in which there
^jftre tooie contractions. If the case is seen soon after the seizure, the
iaduced current will generally be sufficient to produce contractions of
the paiulyzed muscles. The poles, terminated by wet sponges, should
be applied to the skin covering the muscles, or in some cases to the
nerrtss. The current should be strong enough to cause slight pain, or,
if arnsibility is lessened, to produce contraction. In old cases attended
with atrophy of the musclea, and diminished or abolished electro-con-
tzmctiljty, the primary current may be necessary. It should bo applied
in audi a manner as to be interrupted, for contractions are only caused
when the circuit is closed and opened* As the muscles improve in size
mild irritability, the induced current should be used. Care should be
lakaft uot to fatigue the patient, or to cause excessive pain by em-
>fln$( a current of too great a degree of intensity,
Aa regards the restoriitiou of sensibility, it will generally bo found

< MMtk and Forti^ UMitO'Chirur^ical Review^ April, 1868,

* ^omrmnl of i^ydWoj^im/ JIaiicinr, Aprils 1870. The firat thirteen eaace dted in thk
f imblkluHl in Dr. Vance's piper.

108 DISEASES OF THE BRAIN.

to be less difficult than the removal of the motor paralysis. The i
thesia very often disappears or becomes much less spontaneously, and it
does so from the centre to the periphery; that is, if there be anassthesia
of the leg, the sensibility returns in the upper part first, and subsequent-
ly in the lower part. The treatment consists mainly in the use of the
electric wire-brush, which should be passed gently over the skin pre-
viously made dry. The other pole consists of a wet sponge. Either
the induced or primary current may be used. If the latter, however,
be employed, the wire-brush should constitute the positive pole.

I have frequently succeeded in curing almost complete anaesthesia
from cerebral haemorrhage by this treatment alone. In recent eases it
will almost invariably prove effectual. Hyperassthesia, if present, may
be similarly managed.*

CHAPTER IV.

CEREBRAL MEinXGEAL EJEMORREAOE,

By the term cerebral meningeal haemorrhage is to be understood —
1. An extravasation of blood between the cranium and the dura mater;
or, 2. An extravasation into the cavity of the arachnoid between the
two layers of which this membrane is composed; or, 3. An extravasa-
tion into the sub-arachnoideal space between the arachnoid and the pia
mater, or into the tissues of this latter membrane, or between it and
the brain. There are thus — 1. Extra-meningeal haemorrhages; 2. In-
tra-arachnoideal haemorrhages; and, 3. Sub-arachnoideal haemorrhages.
The first are almost always the result of traumatic cause, involving
injuries of the cranium, by which the vessels of the dura mater are
wounded. Extra-meningeal haemorrhage may like^vise be produced by
the operation of trephining, should any of the vessels of the dura ma-
ter be divided.

It is, however, beyond doubt that this species may originate inde-
pendently of wounds and injuries.

The distinction between intra- and sub-arachnoideal haemorrhages
was first pointed out by Prus,* to whom we are also indebted for much
valuable information on the subject.

Of one hundred and seventy -two cases collected by Gintrac,' five

' The subject of the employment of electricity in medicine is too extensive to reoeive
more than sKght notice in a work like the present. For full details in regard to it, the
reader is referred to the author^s translation of Meyer's ** Electricity in its Relations to
Practical Medicine," second edition. New York, D. Appleton & Co., 1872.

* ** M6moire sur les deux maladies connues sous le nom d'apoplexie m^ning^ — ^M^
moires de Tacad^mie de m6decine," tome xi., 1845, p. 18. ' Op, et/., tome L p. 782.

CEBEBRAL UEKINGEAL II^MORRBAGE.

109

extra-meningeal, one hundred and nine intra-arachnoideal, and
tkirty-four sub-arachnoideaL

Symptoms. — ^Themost prominent symptom of mcningenl hfemorrhage
M coma, winch may appear suddenly, or be preceded by premonitory
^qn>^ptom<ii, such as headache, vertigo, and general convulsions. The
stQpor is usually profound, and does not differ from that observed in
tlie peTere forms of cerebral hiemorrbage. The power of motion is
gi(Berftlly lost throughout the body, and consequently there is usually
oo hemiplegia. The reason for this is, that the haemorrhage is so ex-
tensive aa to press upon both hemispheres. Reflex and automatio
SKyrements remain, except when the medulla oblongata is involved,
when 9cime of them are abolished. If the extravasation is iu this latter
fittiAiion, death soon takes place from cessation of respiratory actions.
AMWibesia is present in the skin of those parts in which tbe power of
motion is lost.

In ordinary cases the patient may pass out of the comatose condi-
tion from the fact of the brain becoming accustomed to the pressure,
luid he then may be able to speak, and to move his limbs, but his men-
tftt »Jid physical faculties are greatly enfeebled, and a renewal of th^
bi^morrhagc again plunges him into a state of coma, from which he
■l»y again emerge. This sequence may be repeated several times, until
doatb at last takes place. Before this termination there are vomiting,
iaooiitifi^nce of urine and fasces, insensibility, and occasionally general
oooTuhuona.

In a case reported by Dugast,* a woman entered the Hnpital Neckar
io a sta^te of marked prostration. Her intelligence was not markedly
impaiivcl, but, though she understood almost every thing said to her, she
ansirered only by monosyllables often unintelligible, and pronounced in
A low Toioe* She was affected with paralysis of the left side of the
fmefij tLod att tncnmplete paralysis both of motion and sensibility of
tlie riglit «ide of the rest of the body.

Four days afterward she was in a state of complete prostration, the
pmnXyM w&s geueral. Up to this time the intelligence had remained
almoftt intact, She died that day. llie post-mortem examination
ffaoirc!«l tbe existence of a large aub*arachnoid extravasation at the
base f ' ' kin. On the inferior surface of the pons the blood had

bftcofti- lidttted into a clot which pressed upon the left lobe. On

the right side of the pons the blood had not coagulated. Tins case is
interest in|f aa hearing upon the subject of cross-paralysis already con-
■idi^^d in tbe previous chapter.

It haa sometimes happened that meningeal ha*morrhage, resulting
from an injury of the cranium, has not caused any very prominent
ijnpioiiia for a considerable period afterward. A teamster was struck

^QMliltics eotieid^ratioos but \es b6morrliagie« m^aing^cs cdr^brales. Th^ de

110

DISEASES OF THE BRALV.

on the Iieail by a club iii the liands of another man, was stunned
few minuteSj tlieo recovered, and went about his business witljout eom-
plainiug of his head. In about twelve hours afterward coma sujM>r-
vened, and ho died without being aroused. A case is reporteti by
Dr. Gibson/ in which a still longer period intervened* A man, sixty
years of age, was found one morning, about eight o'clock, seated as
if asleep at a desk, his arms crossed before hitn, and \m head resting
on them. It was discovered that he was profoundly insensible. He
was sent to the hospital, where he lay comatose, breathing stertoroasly,
and paralyzed on the whole of one side. At the end of two days he
died. On post-mortem examination there was found fracture of the
left side of the cranium, with rupture of the dura mater and middle
meningeal artery, from which latter, extensive hicmorrhage had taken
place. It was ascertained that, five days before, he had fallen down a
stone staircase, was stunned for a few minutes, but had soon recovered
his senses. Doubtless during the whole of the intervening period the
bleeding from the ruptured vessel had been going on.

Prus, in the memoir cited, attempts to draw a s\TnptomatologicJ
diBtinction between sub-arachnoideal and intra-araehnoideal h^emor*
rhage. llius for him headache, dryness of the tongue, fever and deliri-
um, are indications of intra-arachnoideal hicmorrhage. Somnolence and
coma are common to both forms, but, when they are conjoined with the
phenomena mentioned, intra-arachnoideal luemorrhage is to be dijig*
nosticated. But most authors doubt if the discrimination can in reaKty
be made during life. Valleix* declares that the difference is of greater
anatomical than symptomatological importance, and Durand-Fardel *
admits that it is difficult to present a characteristic view of the course
and phenomena of sub*arachnoideal hiemorrhage. I must confess that
I see no greater anatomical reason for any difference in the symptoms
of the two fonns of meningeal hfemurrhage than there is for a dif-
ference between indammation of the pia mater and inflammation of the
arachnoid. Neither are there any characteristic symptoujs which would
serve to distinguish hoBmorrhage of the dura mater from either of the
other forms.

Causes, — Among the predisposing causes of meningeal haemorrhage
age occupies the first place. It is more frequently met with in young in-
fants, and in old persons, than in those of middle age, Legendre * in two
hundred and forty -eight cases occurring in infants, and in which post*
mortem examinations were made, found no instance of the child being
over three years of age. Between one and two years would appear
from his researches to be the period in which children are most liable
to the supervention of meningeal hirmorrhage*

* Sdinhnrffh MtdiealJourmlf September, 1870, p, ltf9.

* ** Guide de m^declne praeticien/* tome ii., Paris, 1866, p, 4. 'Op nY, p. ItJI.

* '' Recherchen ear ijuelqoea makdies de Veafaiice." Piiris, 1846, p. l\Z,d *^.

CEREBRAL MEXIN'GEAL n^MORItQAGE.

Ill

fintrac'd * oases are of dilTereut import aa regards this point,
for of one hundred and sixty-five in which tlio ago was noted, only
imo, were under ten years of age, while thirty-seven were between
tlie agoa of thirty and forty, sixty-seven were between fifty-one and
eighty years of age, and two of eighty -seven and eighty-eight years
respectively.

Meningeal hti?tnorrhage is often produced by injuries of the skull^
and results from sudden rupture of a healthy artery or vein. It may
foUow hlowa on the head> falls, or injuries with instruments which
perfonit<? the eraniutn, and may or may not be associated with fnictures
of the bones.

Extreme beat acting upon the head, venereal excesses, severe raus-
cnUr cflTorts, excessive mental exertion, amenrrohoBa, overfeeding, and
coQstip&tion of the bowels, have been cited as exciting causes. The
Ittger ressels, or the capillaries, may give way from being diseased, and
OCMtteqiiently unable to resist the ordinary tension of the blood. Such
^ condition may be the result of the long-continued excessive use of
aloobolic liquors, or may be due to hepatic disease,

ProgHQSis.^ — ^Th© ordinary termination of meningeal haemorrhage is
tieiatJu Of thirty-one cases in old persons, cited by Durand-Fardel,
deith occurred in twenty-six before the end of the fifth day, in one it
took place on the seventh day, in two on the fifteenth, and in two in
trom twenty to twenty-five days. Legeudre, in infants, ascertained the
dtumtion to be from eight to twelve days, Prus found death to ensue in
esaes of &ub-arachnoideal hiBmorrhage before the end of the eighteenth
dMjf but in instances of the intra-arachnoideal form life was sometimes
prolonged for over a month.

Btit recxjvery has occasionally taken place through the formation of
false membranes iu such a manner as to circumscribe tlie extravasation,
mod thtts to conduce to the absorption of its fiuid portion, and Legendr©
hma de«ertbod a process occurring in children by which the sanguineous
eyai U truns^forttied into one containing serum, thus producing a species
oC bydro«*ephalu8. Such ti*rmi nations are, however, so very rare as to
mitigate but to a very slight degree the gravity of the prognosis.

Bll^naosis. — The diagnosis of meningeal haemorrhage is a matter of
amch " " V, Still, there are certain clmracteristics which aid us

•one^ ' rriving at a correct opinion. Thus, from cerebral hicmor-

rliage, it may usually be distinguished by the fact that the coma, when it
ousts, corner on gradually, that the headache is a much more prominent
symptom, that there is not often hemiplegia — the paralysis amounting
to a gcneml rt^solution — and above all, by the remissions which so fre-
qticsitly mark its course. Durand-Fardel ' declares that when the coma
and general abolition of the faculties indicate the existence of strong
oetrebnd pressure not accompanied by paralysis, properly so called^ or

Op,dL,p. IU,

Op*cii,,p. Ids,

112 DISEASES OF THE BRAIN.

only by incomplete paralysis, perhaps more strongly marked on one
side than on the other, we may suspect the presence of meningeal hasm-
orrhage; that a cerebral haemorrhage, or an acute softening sufficiently
extensive to produce such pronounced symptoms of compression is
always accompanied by complete paralysis involving a lateral half of
the body, and that the full development of the phenomena is ordinarily
preceded by violent headache.

From cerebral congestion the diagnosis must be occasionally almost
if not altogether impossible, and the same is true of cerebral softening.
The remissions when present in meningeal haemorrhage will afford im-
portant assistance in establishing the existence of the disease, but when
they are absent the difficulties in the way of an exact discrimination
may be insurmountable.

Morbid Anatomy and Pathology. — An extravasation of blood be-
tween the cranium and the dura mater, extra-meningeal hsemorrhage,
is, as has already been said, almost invariably the result of traumatio
cause. Gintrac,* however, with his usual industry, has collected five eases
in which it appeared to be idiopathic. The first of these he quotes
from Dr. J. H. Wythes,' of Port Carbon, Pennsylvania, but he omits to
state that the child had been playing on the door-step, and that a pain
in its ankle was supposed by the parents to have been due to a sprain.
It is probable, therefore, that the child fell and struck its head. The
next morning it was found dead in bed. On post-mortem examination,
an extravasation of blood, amounting to about half an ounce, was
found between the skull and dura mater, on the upper surface.

In the other cases the blood appears to have been effused during
extreme congestion of the meningeal vessels, one or more of the latter
having given way under the excessive tension to which they were sub-
jected. In one quoted from Abercrombie, there were numerous dots
scattered over the interior surface of the dura mater, and which seemed
to have come from the Pacchionian bodies. These elevations were
very vascular, being gorged with blood.

The anatomical characteristics of intra- and sub-arachnoideal hsem-
orrhages have been very thoroughly given by Prus.' In the former
the blood is extravasatcd by exhalation, that is, there is no visible
rupture of blood-vessels, and, if life be prolonged to the foiurth or fifth
day, a false membrane is formed by which the clot is retained in appo-
sition with either the parietal or visceral layer of the arachnoid. This
membrane eventually becomes organized by the formation of vessels in
it, and may, therefore, be the source of another haemorrhage; for, as
Charcot and Vulpian * have shown, these vessels are numerous, large,

* Op. cii.^ tome i., p. 646.

• " Three Gases of Infantile Apoplexy." Xorih American Medico-Chirurgieal Revitw^
January, 1868, p. 70.

» Op. et he. cit, * Gazette hebdomadaire, 1860, pp. 728, 789, 821.

CEREBRAL HEiVlNOEAL ILSMORRnAGB.

113

id of very thin walls, and arOj thcrcforej in a favorable condition

way under the tension of the blood*
idet * previous to Prus had described the false membranes which

y 50 important a part in intra-meningeal ha>morrhage, and had
pointed out their resemblance to the arachnoid and their liability to be
ilie source* of other hi^inorrhagest, and at about the period of Prus's pub-
Ucation 3lr. Prescott Hewett * called attention to extra vasationB at-
tached ti> the free surfaco o£ the ai*aehnoid, and kept in position by
a fal86 membrane not distinguishable by the naked eye from a true
serooa membrane.

The clot may be extensive, covering nearly the whole surface of
a hemisphere. The vessels which have given way, and have thus
produced an intra-arachnoideal h<emorrhage, are usually found in an
atheromatous condition, and the vessels of the neo-membranes are es*
pecially liable to be thus diseased.

Dr. Sutherland * in a very interesting memoir gives the details of
IfH MMsa of arachnoid cysts occurring in the insane : *' On removing the
iirell-IMp And dura mater, instead of the convolutions of the brain, with
its Taacolar pia mater meeting the eye, there appears a reddish, pulpy,
fitiotmiting swelling on the surface of the brain, having such a uniform
appearance that the outline of the convolutions beneath it is invisible.
On attempting to strip oft the cyst from the surface of the brain it is
ttitiaUy found adhering to the visceral arachnoid along the centre of
llie luiigitudinal fissure ; it is easily separated from the convolution*
UQ eiilier aide ; but if large enough to embrace the entire hemisphere
ia fofimd a^in to be adherent below, but in this situation usually to the
parietal layer of the arachnoid membrane.^'

Of this ton cases reported by Dr. Sutherland, four were in all proba-
bility due to injury of the head. In live the mental aberration was
of^l^iiic dementia, in three general paralysis, and in two idiocy and im-
bceiJitr.

In fuh^rachnoiihal haemorrhages the blood is, as we have aeen, ex-
Ifmraaatifd into the space between the arachnoid and the pia mater, and
ia often entangled in the meshes of this latter membrane, Aa the
blood when extravasated is mingled to a greater or less extent with the
CiETobfO-spinal fluid, it often remains liquid. The quantity thrown out
m frequently very large, amounting in some eases to apparently as
mneb as aix teen or even twenty ounces. These tigures must, however,
be taken with some allowance for the amount of cerebro-spinal fluid
with which the bloo<l is combined.

< ** liteolrt tar rh^morrhft^e det mdmnges,** Jourtud det
, 1990.

« JMki» ChirmgietU IVanMuHonM, vol zxvlil, 1846,

< *' AfschfiAld C?a«." '* Wi»t Etding Lunatic Afljlum Medical E^porto/* toI I, 1871,

114 DISEASES OF THE fiRAIN.

The anatomical relations are such as to admit of sub-arachnoideal
haemorrhages being very extensively distributed throughout the oranio-
vertebral cavity. In one case in which I made a post-mortem examina-
tion, it occupied the whole base of the skull, and, in a case cited by
Prus, the whole base of the cranium was filled with blood, all the ven-
tricles were in the same condition, and even the sub-arachnoid cavity of
the spinal cord was invaded.

New membranes are never met with in this form of meningeal luem-
orrhage. Atheroma of the arteries, especially of those at the base of *
the cranium, is the disease which is ordinarily the inmiediate cause of
the extravasation, and the torn vessel can generally be discovered with-
out difficulty. Aneurisms of the basilar, the internal carotid, or other
arteries of the base of the brain, have by their rupture been the cause
of sub-arachnoideal haemorrhage.

Treatment. — lliere is nothing to add under this head to the remarks
already made relative to the management of cases of cerebral haemor-
rhage.

PACHYMENINGITIS AND HJEMATOMA OF THE DURA MATEB.

A peculiar f onn of meningeal haemorrhage, called haematoma, is met
with under the dura mater. Tlie blood is not diffused, but is collected
in sacs which are formed of false membranes, the result of chronic in-
flammation of the dura mater; or pachymeningitis as it has been desig-
nated by Virchow. These capsules are flattened ovals in shape, are
three or four inches in diameter, and half an inch thick. They are
usually situated at the vertex, and involve both hemispheres. When
this is the case, the paralysis which results is bilateral.

Symptoms. — The initial symptoms of haematoma of the dura mater
are the results of chronic inflammation, and are slow in their progress.
In many respects tliey resemble those indicative of softening, and consist
of weakness of intellect, vertigo, a dull, circumscribed, persistent pain,
and more or less tendency to stupor. The power of motion is generally
diminished on both sides of the body, though occasionally there is
hemiparesis. Paralysis is scarcely ever complete. Contractions of the
limbs and twitching of the muscles, especially of those of the face, have
occasionally been observed. Gradually, through a period extending
over several months, the stupor increases, and finally the patient be-
comes apoplectic. During the whole course of the disease the pupils
are strongly contracted. The patient dies comatose and frequently
convulsed.

Causes. — Early and old age are both predisposing causes, the disease
being met with mainly in children and very old persons. It is frequently
seen in the insane, and may probably result from rheumatism, the ex-
cessive use of alcoholic liquors, and fevers. The cause is sometimes to
be found in wounds or injuries of the skull.

CEREBRAL MENINGEAL HAEMORRHAGE,

Diagnosis. — It is doubtful if haematoma of the dura mater can be
definitely recognized either in the stage of infiammationor that of hjem-
orrtiage. Legendre * states that, in children, the most important diag'-
nostic mark is the permanent contraction of the hands and feet, which
18 so generally present; but this symptom is certainly met with in other
etrebral disorders, and may even result from reflex irritations. The
diji^ttosis is rendered still more difficult by the fact that the disease
under consideration is often associated with other cerebral disonlers
which mask or modify its symptoms. The absence of fever, the con-
traction of the pupils, the slowness and irregularity of the pulse, the
facts that there are no vomitings and no general convulsions, that the
fes distributod to the several parts of the face are not paralyzed^
It there are constant and very severe headache and a gradually in-
onasing tendency to stupor, are, according to Jaccoud,^ sufficient to
|)ie presence of ht'ematoma of the dura mater. I am of the
It they only enable us to give a guess which has some basis
in probability, for I have several times witnessed exactly such a condi-
tJcMi aa that described, and after death fcund other morbid conditions
(ban lupmatoma.
I - Prognosis. — ^This is unfavorable, death resulting sooner or later, ac-
' Mmfiog to the extent of the disease and the natural powers of the
patt«iit

Horbid Anatomy and Pathology. — The first stage of htematotna of

tlio dura matter i«t characterized by the formation of the false mem-
liranea, to which allusion has already been made. These membranes
axe found on the internal surface of the dura mater, and are reticukted,
praiaeiitiQg somewhat the appearance of spiders^ webs. They generally
haiTtt their seat near the sagittal suture, and extend to both hemispheres,
being only separated from them by the arachnoid and pia mater.
ViKfhow, who has studied their formation with greater care than any
otlier obitrvcr, has found more than twenty layers of them, one on top
of theotiier, and traversed by numerous blood-vessels.

Owing to this great vascularity, to the extreme tenuity of the vessels,
and to the absence of any perivascular support, ha3morrhage is liable to
oeetir, ami the several lameUae thus constitute a sac into which the blood
nay he poure<L This, pressing upon the cerebrum below, and con*
staatly being enlarged by subsequent ha?morrhages, gives rise to the
fjmptoaia obseired during life. The vessels may be more liable to rup-
tBro ffofn t? ' noe of atheromatous degeneration of their coats.

Anatoti . I 1 pathologically hjematoma of the dura mater differs

irom inira-arachnoideal h:Bmorrhage in the facts that the extravasation
m between the dura mater and parietal layer of the arachnoid, and that
tbe fonnation of the membrane precedes the hieraorrhage. Those

* "Rechercbes sor qiioltines malftdies de Teafiincc," Paris, 1910.
■ ** Traill df9 pAthologie mterae," lome I, Ptm^, tSTO.

116 DISEASES OF THE BRAIN.

authors who regard the arachnoid as consisting of but a single layer,
and who consequently do not admit the existence of intra-arachnoideal
haemorrhage, must consequently concede that there are two kinds of
cxtra-arachnoideal haemorrhage, one in which the membrane forms sub-
sequently to the appearance of the extravasation, and the other in which
the haemorrhage is the direct consequence of the formation of the mem-
brane.

Others again, as, for example, Gintrac and Durand-Fardel, evidently
regard what they describe as intra-arachnoideal haemorrhage, as iden-
tical with haematoma of the dura mater ; and it is quite certain that
many of the cases adduced by Gintrac as examples of intra-arachnoi-
deal haemorrhage are in reaUty instances of pachymeningitis with sub-
sequent sanguineous extravasation. The difficulties in the way of a
complete understanding of the subject are greatly lessened by remem-
bering the distinction pointed out above, that haematoma of the dura
mater is a secondary affection, the direct result of inflammation and the
formation of false membranes; while in intra-arachnoideal haemorrhage
the membrane is derived from the extra vasated blood, which is the first
step in the morbid process.

The size of the cysts is subject to much variation, the quantity of
blood ranging from one or two to sixteen or even more ounces. By the
pressure which they exert upon the brain, the convolutions are flattened,
and even softening of the cerebral tissue may be produced.

Treatment. — ^This requires no amplification at my hands, as I do not
believe in the efficacy of any means for curing the affection. All that
can be done is to palliate the more violent symptoms, such as the head-
ache and feebleness of mind and body, by anodynes and stimulants, and
of these, morphia administered hypodermically, and alcohol in some one
or other of its numerous forms, are to be preferred. Bloodletting and
blistering are worse than useless.

CHAPTER Y.

PARTIAL CEREBRAL AKjEMIA FROM OBLITERATION OF CEREBRAL BLOOD-
VESSELS {ISCHjEMIA).

Obliteration of cerebral blood-vessels may take place —

1. By thrombosis of the arteries.

2. By embolism of the arteries.

3. By thrombosis of the veins or sinuses.

4. By embolism or thrombosis of the capillaries.

I. — ^THROMBOSIS OF CEREBRAL ARTERIES.

By cerebral arterial thrombosis is understood a condition in whiob

PABTUL CG&EBBAL ANOXIA, ETC.

11-

i of the brain undergoes narrowing of its calibre by the depo-
sition of tibrine from the blood on its internal surface. The dot thus
^ fanned is called a thrombus.
^XHptoms. — The phenomena observed in consequence of the forma-
tion of a thrombus in a cerebnil artery are gradual in thoir development,
^Dd arc often interrupted by stages of apparent improvement* Ilead-
ifcche, as in so many other affections of the brain, is a prominent symp-
tom and is almost constantly prcsonti It is not usually diffused over the
whole head, but oecuples a place ha\iiig a close relation in situation
with the seat of the disease. It is rarely of a very aggravated charac-
aeier, and is remarkable rather for its persistency than its seventy. In
several cases which have come under my notice, the pupil of the eye of
the affected side was dilated from the first, and there were ptosis and
strabismus, showing that the third nerve was involved.

At m very early period in the progress of the disease it is not un-
eominaii to meet with marked difficulties in the faculty of speech, and
|1hm€ not only relate to the articuhition, but to the memory of words.
As rcigards the first-mentioned form, there may be restraint in the
movements of the tongue, the lips, or both, or there may be a loss of
ooOfdmatijig power in the muscles concerned in speech without any
actual paralysis. Special inconvenience is, therefore, experienced when
atteinpts are made to pronounce words in which the labial and lingual
fetters arc prominent. The gutturals in such cases are enunciated
witliout difficulty. In the other form in which the memory of words is
ODpair^, the patient is constantly at a loss for language with which to
expreSB bis ideas; and, though the proper words may be supplied to
htm, lie ftlmost immediately forgets thera again. Tlie full considera-
tioQ of this interesting subject will be found under the head of aphasia.
Vrrttgo, though generally present, is not usually severe, at least in
^e early stages.

Thu incipient symptoms of paralysis soon miike their appearance
ill the majority of cases, and, though there is a gradual advance in the
I power, there are periods of almost entire remission. Thus the
' tlie arm, or the face, may be the original seat of the paralysis,
and cv<mtually the whole of one side be involved. In a case of prob-
able tbrombosis in a gentleman now under my charge, the paralysis
was at fist limited to the muscles supplied by the ulnar nerve and
those concerned in deglutition* For one period of five days after I
irat ssw him, there was an entire remission of his symptoms, and he
eoiiU move his hand and swallow as well as ever, but gradually the
power was sgain lost, and other muscles became involved. At the
L preseat time he is almost entirely hemiplegic,

H Seostbility is also generally abolished or impaired on the paralyzed

B mUi, and thus the various forms of numbness, such as tlngliTig, formi*
^^^plioii, etc., are present.

L :

118 DISEASES OF THE BRAIN.

The mental symptoms are usually apparent from the first, but may
be altogether absent or else so slightly shown as not to attract atten-
tion. The memory is impaired, not only as regards words, to which
reference has already been made, but also events and circumstances,
especially those of recent date. The names of persons and things are
likewise readily forgotten. In the case of a gentleman whom I saw in
consultation, and in whom I diagnosticated thrombosis, there was left
hemiplegia involving both arm and leg, but not the foot, which had
begun in the fingers and gradually extended. There was no special
difficulty of speech except as regarded the recollection of words, but
the memory was wonderfully impaired in every other respect. I en-
tered his room upon one occasion just as the servant was carrying out
a tray with the remains of his breakfast. Not three minutes had
elapsed since he had eaten, and yet he assured me he had tasted noth-
ing since the day before. The loss of memory was the first symptom
observed in this case. Soon afterward he began to improve, and he is
now, after fifteen months, free from paralysis, and with his memory
almost as good as ever. The loss of memory in such cases seems to be
due in the main to the fact that the power of concentrating the atten-
tion upon any subject is very much diminished. There is likewise an
indisposition to exert the powers of the mind or body, and thus the
patient tends to pass into a condition of apathy. Somnolence is a fre-
quent symptom.

An interesting case * of what was probably cerebral arterial throm-
bosis was admitted to the New York State Hospital for Diseases of the
Nervous System, August 22, 1870, and came under my observation.
The patient, a man forty-one years of age, was temperate, and had
never had either syphilis or rheumatism. In March, 1868, he was seized
with a dull pain in the right knee, accompanied with numbness* There
soon followed formications and pricking sensations, limited to the right
foot. These gradually extended upward, and, at the end of two weeks,
had reached the shoulder, when he became entirely hemiplegic. Dur-
ing this attack his consciousness was not affected, and his organs of
special sense, except his touch, were unimpaired. On the 11th of
May following, the patient suddenly lost the power of speech, but ex-
perienced no disturbance of consciousness. He remained completely
aphasic for four months, being only able during this time to utter a few
sounds which could not be interpreted into intelligible words. He theo
began to enunciate a few words, and gradually acquired more facil-
ity, though his power of coordination was far from perfect when he
came to the hospital. His paralysis remained complete for nearly a
year.

Wlien admitted there was hemiplegia of the right side of the body

1 Sec the author*s " Clinical Lectures on Diseases of the Nenroafl System." New York,
1874, p. 1. Case reported by Dr. T. M. B. Cross.

PARTIAL CEREBRAL ANJEMIA, ETC.

re face; his eyesio^ht, hearing, and other special senses, were
imiinpaired, and his intellect was cl«ar. There was no loss of the mein-
of words, and no impairment of the motor power of the tongue, but
'iliriply a defect in the faculty of coordination of the muscles used in
articulation. There was more dithcuUy in pronouncing labials and Un-
guals than gutturals. Tactile sensibility, electro -muscular sensibility,
aim] fson tract Uity, together with the temperature, were markedly dimin-
ijfchifd in the right arm, wliile sensibility to pain and deep pressure was
BorraaL The bladder and rectum were not paralyzed.

In talking, ho had a peculiar hesitating, stammering manner, highly
obamcTtcTiatic of his disease. There were certain words which lie was
lotallir unable to pronounce with any degree of accuracy, ev»in after
iDno!i effort — *' Peter Piper" — worda which begin with explosive hibial
fetters^ and others similarly constructed troubled him greatly. The
opbtlialmoaoope showed the existence of atrophy of both of the disks,
md of retinal anemia.

TTnder the use of strj'chnine hypodennically administered, phospho-
ma, and the primary current to his brain and the faradaic to the para-
lyzed parts, very marked improvement in all his symptoms was produced,
Uo regained a considerable amount of power in the arm, became able
lo wmlk several miles at a time, and acquired the ability to articulate
dtstinotly any words he wished to say. The sensibility returned, and
Ihe nutrition of the affected limbs was manifestly improved.

In another case, also the subject of a clinical lecture,* there was
r hot the basilar artery. The patient, a woman, aged

It work wringing out clothes and exerting a good
faroe, experienced a sensation of numbness in the right arm and

"#lljeh was attended with slight loss of power, though not enough to
emnam bor to desist from her labor. At the time of the attack there
were no heod-symptonis of any kind, and she noticed no paralysis of
tbe bee, iler spoech was not affected. At the time of her admission
into ihm New York State Hospital for Diseases of the Nervous System,
tliere was paralysis of motion and sensibility of the right arm and of
motioo on the left side of the face,

Tbe ease was therefore one of crosa-paralysis, and it was this fact
wUoh mainly induced me to locate the lesion in the pons Varolii

TImi speech was indistinct, but this was manifestly due to paraly-
mM of the tongue and of the other tnuscles concerned in articulation.

In the case in question there had been acute articular rheumatism,
bat llie heart was free from functional or organic disease. The attack
waa not manifested with the suddenness which characterizes embolism,
and tkero were no loss of the faculty of language, and no mental dis-
taitwoef;, which would probably have resulted had the middle cerebral
arteij boen oocluded* Besides, the face and the limbs would have

< Op, dt, p. 130,

120 DISEASES OF THE BRAIN.

been paralyzed on the same side, all of which considerations induced
me to believe that the case was one of thrombosis of a limited portion
of the basilar artery.

During the first stage of thrombosis, before the artery is entirely
closed, amendment, and even complete recovery, may take place. ITie
remissions in the symptoms already referred to are due to the establish-
ment of the collateral circulation, and this may become so complete as
to eventuate in cure. It must be confessed, however, that the condi-
tion of anaemia to which the foregoing s3rmptoms are due, in the great
majority of cases ends in softening — a subject which will presently be
considered as one of the consequences of thrombosis and other morbid
states.

Causes. — Thrombosis of an artery may result from atheroma or
from endarteritis, by reason of which its elasticity is diminished and
the smoothness of its lining membrane destroyed. Both these condi-
tions retard the course of the blood, and favor the deposition of fibrine
on the internal periphery. The walls of the vessels may be healthy,
and a thrombus may then be formed through a weak action of the
heart — the result of fatty degeneration or other cause impairing its
strength.

Certain conditions of the system, such as that which accompanies
rheumatism, may induce thrombosis through the excessive amount of
fibrine present in the blood and which renders this fluid more readily
coagulablc. It is probable, also, that other diseases and particular
articles of food — as, for instance, alcohol, fat, and starch — when taken
in excess, especially when conjoined with insufficient physical exercise,
may so alter the composition of the blood — inducing hyperinosis — as to
lead to a like result. Inordinate mental exertion, tending as it does to
diminish the tone of the arteries by keeping them in a condition of over-
distention, may likewise cause the formation of thrombi.

It has apparently resulted from exposure to intense heat, from sup-
pression of the menstrual flow, from severe emotional disturbance, and
from blows on the head.

It is much more common in males than in females, and in persons of
advanced years than in the young.

Pressure may be exerted upon a cerebral artery by a tumor or other
extraneous body, and narrowing of its calibre and a consequent throm-
bus be produced. Gintrac * cites a case of the kind. A young man
had suffered for several days with Readache and loss of power in the
lower extremities. Coma supervened, but he was still able to answer
questions. There was then pain in the back of the head, the pupils
were dilated, the mouth was drawn to the right, the respiration was
laborious but not stertorous, and the left side became completely
paralyzed. He died on the fifth day. On post-mortem examination a
1 Op, cU,y tome i., p. 444. Quoted from Roupell, Medical TimeB, 1844, toL ix., p. 870.

PARTUL CEREBRAL AK^MU, ETC.

121

biBfi

■ vein

I
I

bund to occlude the ri^ht middle cerebral artery, and it
;lenJed to the internal carotid artery, but did not pass into the middle
oerebral artery beyond the point of obstruction. At this place in the
fiasure of Sylvius a small granulated mass, something like a Pac^hi-
oaiasi gUnd^ pressed upon the artery and closed it. In such a case the
•yitiptt»ms will of course be developed with much g^renter rapidity than
nrheti the cause of the occlusion resides in the artery itself.

DiagfQOSis. — Arterial thrombosis is distinguished from cerebral oon-
gf&iion by the facts that the mental and other symptoms are more pro-
lotind in character, and that the patient has generally passed the prime
d Me. The ejiistence of paralysis among the early symptoms will
likewise tend to the formation of a correct opinion. From cerebral
hieiiiorrhage it is diagnosticated by the circumstance of its gradual de-
velopment; from encephalitis by the absence of fever and the more
chronic nature of the disease; and from embolism by its slow progress
th© impossibility of defining the exact period of its beginning*

Prognosis. — The prognosis in cerebral arterial thrombosis is unfa-
vomble, for the reason that, although the morbid process may advance
slowly, and may even be spontaneously arrested in its course befortj
the artery is closed, the tendency to complete obliteration is always
great, and the chance of sufficient circulation being carried on by the
collateral vessels 15 very remote. The disposition to softening, there-
fore, always exists, and generally cannot be overcome. The inade*
quaoy of any medical treatment to control the action going on within
thm artery, or to aid to any great extent in the development of the
collateral circulation, is also an element in fonuing an opinion as to the
oliimate result.

Morbid Anatomy and Pathology.^— Although Virchow * was the first

to write ilistinctly in regard to the nature of thrombosis, the conditiorj
wmB rocogmzed long before his researches were made, and cases of clots
|plBggtt^ Up the vessels are to be found detailed by many of the older
Bieflieal authors, among whom Abercrombie^ Carswell, and Cruvcilhier,
iiiaj be mentioned. Since Virchow began his observations in this direc-
tifMii tiuuiy instances have been recorded and a largo number of memoirs
kale been issued upon the subject. An interesting case was related by
Or. Packard,* of Philadelphia, at a meeting of the Pathological Society
of that city held in December, 1859, The patient, who ha<i been under
the eare of Dr, Heller, was a bachelor, fifty-one years of age. At six
o^ekiek in the morning, at the beginning of February, he was seijted with
panljaia of the left arm and leg. He was a man of very regular habits,
and of fanatical love for every thing inst motive, and an accomplished
■eltnlar in botany, geography, and languages. The paralysis was soon
fcfiered, and he was able, four weeks afterward, to go out again and to

[>'» Xfit^ yofUm, 1M6, Heft xxxviL
I Amrrican Mffiit-o^Chirur^ral Revitto^ vol, it., 1860, p, 8(MI,

122 DISEASES OF THE BRAIN.

use his arm tolerably well. About the middle of March, in coosequenoe
of a fatiguing walk the previous evening, and an attack of diarrhoea
during the night, complete paralysis returned. From this he never re*
covered, but yet did not die till the December following. Previous to
this termination he had confusion of ideas and delirium. Upon post-
mortem examination, among other morbid changes, a cavity in the right
corpus striatum was found, and this was surrounded by a spot of soft-
ening of the cerebral substance as large as an egg. The basilar artery
was completely blocked up with clots, as was also the right carotid.,
These vessels were atheromatous, and the basilar artery was aneuris-
mally dilated. The clots had all the appearance of being old.

Dr. Dickinson ' has brought forward five cases of occlusion of arte-
ries, several of which I am disposed to think were of embolism, instead
of thrombosis, as he considers them to-be. Dr. Dickinson nowhere
alludes to Virchow's investigations, but gives the whole credit of the
discovery of the relation between emboli and the formation of concre-
tions in the heart to Dr. Kirkes. The conclusions which he draws from
his cases are by no means original, although he evidently so reg^ards
them.

The questions to be considered in connection with the morbid
anatomy of arterial thrombosis relate to the condition of the artery, the
nature of the clot, and the changes which take place in those parts of
the brain which are deprived of their due supply of blood.

The affections of the artery, being similar to those which render it
liable to rupture, need not be dwelt upon at any length here, as they
have already been noticed under the head of the morbid anatomy of
cerebral hiemorrhage. Suffice it, therefore, to say that endarteritiB and
atheromatous degeneration are the diseased states generally met with.

The calibre of the diseased vessel is diminished and the blood is
therefore primarily obstructed in its course even before the beg^inning of
the formation of a clot. In addition the internal coat of the artery is
roughened, and hence the fibrino of the blood is readily caught and de-
posited on the internal periphery. Little by little the layer becomes
tliicker from fresh accretions, until finally the vessel is entirely occluded.

The clot which closes the vessel is, in the beginning, coagulated blood,
and hence consists of fibrine and white and red blood-corpuscles. It
adheres to the arterial wall and may be of a brown, yellow, gray, or
white color. The consistence is greater at the base than at the pe-
riphery, and it may contain granules of calcareous matter composed
mainly of phosphate of lime.* The elements, with the exception of the
fibrine, are gradually disintegrated and washed away by the current of

* " On tlie Formation of Coagulae in the Cerebral Arteries.** St. Qeoige*8 Hospital Re-
ports, voL i., 1866, p. 257.

' Lancercaux, ** De la thrombose et de I'embolie c^rebralcs. Th^ de Paris,'* 18SS,
p. 86.

PARTIAL CEREBRAL ANAEMIA, ETC

128

Hooa witicii continues to flow through the vessel before it is entirely
clused, and thertjfore the iayers nearest the arterial wall consist almost
entirely of fibrlae, and the one nearest the centre of the vessel, which is
th^ Utest formed, of fibrine and corpuscles. An examination of such a
dot "witii the microscope shows that the above-mentioned morphological
elements arc found in its centre, more or less changed, however, accord-
iQg to tile age of the formation. A thrombus may undergo purulent
fofteojfig and diaintegration to such an extent as to result in its break-
ing ap into fragments, which may lodge in the vessel or its branches
fartlipr on, and thus constitute emboli.

The region of the brain to wliich the artery undergoing occlusion is

i>iated is, of course, deprived to some extent of its blood, and hence

BQts at first an appearance of anaemia. And this is not prevented

hf the increase of the collateral circulation, which is never sutBciently

v^proiis to compensate entirely for the loss by the primary vessel.

Microscopic examination shows the capillaries to be smaller and less

I than in the normal condition, though there is not any palpa-

Jig.

But after the artery is entirely closed a change ensues. The aniemic
portion of the brain becomes red or pinlc, and this color is deepest on
tlif* borders, owing to the collateral circulation which is now fully es-
tabUabed. This stage has been called red softening, but I am disposed
10 tbtnk the designation erroneous, and that it is liable to convey fab©
ideas of the pathology. For it is perfectly possible at this time for the
aOMlie portion of the brain to be restored through the activity of the
OoDatCfml circulatioti, with the effect of causing a cessation of the symp-
Itp iiowever, this should be insufficient to provide for the due
the affected region, softening takes place, and a cure be-
Bt impossible.

Obliteration of a cerebral artery by thrombus does not always pro-
duce notable symptoms. For these to foDow, the morbid process must
be at;! ttp in a vessel with but few^ and small collateral branches. Tims,
if the tatenial carotid be obstructed, tlie cLroulation is carried on through
the cifde of Willis by the supply of blood derived from the vertebrals.
The beailar artery might also be occluded at any limited region between
a pair of transverse arteries, and the circulation stUl kept up by the
oara^ids on the one side, and the vertebrals on the other. But any
i:iflatire so as to involve one or more of the transverse arteries nmst lead
to aQaattta, and subsequent softening of the pons Varolii. Thus, in a
reported by Bennett,* in which there had been vertigo and other
^ for several years, and in which paralysis of tlie left snn,
il loss of consciousness, bad suddenly supervened, the basilar
mftmrj was found entirely obliterated throughout its entire extent, all

> ** Cnakal Loetitrci on the rrinciples ^nd Practice of Mottlcine/* ihinl editioa, Eilln*
IMO^ p. S7i).

124

DISEASES OF THE BRAIN.

the transverse arteries were of course closed, and the supply of blood to
the pons was cut off on both sides of the mesial line.

A somewhat similar case has recently been reported to me by a
physician of this city. The patient had suffered with paresis of all the
limbs, with pain in the back of the head, occasional vertigo, irregu-
larity of the respiration and circulation, and double facial paralysis for
several months. He died suddenly while sitting quietly in his chair.
On post-mortem examination the basilar artery was found occluded,

Fia. 15.

cr. artery of thecorpns eallosam (anterior cert'bml, ri^htV, 6, middio cerebral artery; c, pofiterior c

artery; rf, superior cerel>eUar artery; f. anterior Inferior cerebellar artery; /, posterior inferior «»•
bcllar artery; (7, obliteration of artery of corpus callosum (anterior cerebral, riffht); *, oUiteratkMi«f
middle cerebral artery ; i, obliteration of basilar artery ; it, obliteration of vertebral artery (JiOtty,

and distended by a thrombus which reached from the point of union of
the vertebrals to the posterior cerebral arteries, into the left one of
which it extended two or three lines.

A very interesting^ memoir by Hayem * alleges occlusion of the
basilar artery by thrombus to be a cause of sudden death. In all his
cases, four in number, the artery was closed throughout a great part of

* '* Sur la thrombose par art^rite du tronc basilaire, comme cause du mort i^de.**
Archives de Phytiologie Nortnalc et Pathohgique, 1868, p. 270.

PARTIAL CEREBRAL AN^MU, ETC.

125

\ extent, as the result of extensive arteritis and the formation of dense
clots- In the fourth case there was alno thrombosis of the left middle
cerebral artery, with difficulty of speech*

The cerebral vessels most liable to be closed by thrombosis are the
internal carotid, the middle cerebral, the basilar and the vertebral ; after
these come the anterior cerebral, the posterior communicating, and the
postenor cerebral. It is by no means rare to find two or more arteries
flimultaneousty aflfected, and in one case cited by Gintrac ^ the whole
circle of Willis was obstructed, and, in a remarkably interesting case
described by Heubner/ the right anterior cerebral artery, the left
BUiMle cerebral, the basilar, and the left vertebral were obliterated
by thrombosis of syphilitic origin (Fig. 15). The arrows in the figure
represent the course which the blood took by reason of the several ob-
structions to its circulation.

The vessels the closure of which produces the greatest disturbance
o( function are the anterior, middle, and posterior cerebral, which supply
the liemispheres, the corpus striatum, optic thalamus, and other impor-
tiOt gmnglia. Besides the e^ect due directly to the amY5mia, more or
iesB disturbance results from the congestion posterior to the clot, and
the cotisequent effusion of serum.

TreatmeBt — A knowledge of the morbid anatomy and pathology of
(ipinbml arterial thrombosis must satisfy us of the insufficiency of any
medicttl treatment to cause the absorption of the clot obliterating the
ehikitQel of the artery. Yet I have several times heard it gravely pro*
to administer the iodide of potassium, with the view of aocom-
ftg this object. As regards facilitating the establishment of the
eoUatcral circulation, Nature will generally take care of this, and may
eti BO far overdo it as to cause hcemorrhage from the rupture of ves-
not accustomed to the increased tension of the blood. It may
therefore be necessarT, in this latter condition of excessive action, to
ire the bromide of potassium in large doses. Should the ctrculation
feeble, the skin cold, and the patient disposed to somnolence, we
I to suppose that the collateral circulation is not being formed
soffiiuent rapidity, and therefore the patient should be kept with
lbs boftd lowy brandy or other spirituous liquors administered, and the
bo ! ped up in warm blankets,

i ke time after the successful establishment of the collateral eir-
dUAtioQ there is more or less feebleness of mind and body. For this
cofidittoit strychnia and phosphorus are especially applicable, and may
be scbninistered according to the formulas recommended under the
btaiii of cerebral oong^stton and cerebral haemorrhage. Electricity is
. always useful.

1 Op. mi,, p. 44S.

• ** Di« LueUsohe Erkmnkung der Himarterien,'' Leipxig. 1674, pp, 87, 194.

126 DISEASES OF THE BRAIN.

II. — EMBOLISM OF CEREBRAL ARTERIES.

Embolism is the term applied by Virchow to the closure of an ar-
tery by an embolus, which is a clot formed in some other part of the body
and transported by the current of the blood to the vessel which it oc-
cludes. It therefore differs from thrombosis in the facts that it is not
associated with previous disease of the artery, and that the closure of
the vessel is sudden.

Symptoms. — In cerebral embolism there are no premonitory symp-
toms. As in cerebral hsemorrhage, the patient may be sitting per-
fectly quiet when he suddenly loses consciousness and falls to the
ground, comatose. As the stupor passes off, he finds that he is par-
alyzed upon the side of the body opposite to the seat of the lesion.

Or there may be no coma, but merely slight confusion of ideas for
a moment or two with sudden accession of paralysis on a limited por-
tion of one side, involving only the arm or leg. Or, again, the face or
the tongue may be the only part paralyzed. Or there may be no
paralysis anywhere, and no mental symptoms except as regards the
faculty of language, which is entirely or partially lost.

Sometimes there are ocular troubles, such as ptosis, strabismus, or
blindness.

Experience shows that the embolus, for reasons which will be given
hereafter, generally lodges in the left middle cerebral artery, and that
with the right hemiplegia — if there be paralysis at all — ^there is often
aberration of the faculty of speech.

The symptoms of mental derangement, with the exception of the coma
of severe attacks, are not ordinarily prominent. I have, however,
witnessed several cases in which they formed a very striking feature of
the case. In one of these, in which the clinical history of the patient
disclosed the pre^xistence of several attacks of acute articular rheu-
matism, with subsequent endocarditis and mitral and aortic valvular
lesions, there were hallucinations and delusions in addition to the
complete paralysis of the left side. All these phenomena entirely dis-
appeared within thirty-six hours. This case is one of the few in my
experience in which the embolus had occluded an artery on the right
side of the brain.

In another, likewise with valvular disease of the left side of the
heart, there was delirium from the first, and this disappeared as the
collateral circulation was established.

Erlenmeyer has written very excellently of cerebral embolism, but
is, I think, incorrect in some points of his symptomatology. He states
the ordinary phenomena of an attack to be as follows:

There are no prodromata; sudden loss of consciousness, with pa-
ralysis of several parts of the body. The facial, the hypoglossal, and
the nerves of the extremities, are always more or less affected. Senai-

PARTIAL CEREBRAL AN'^MU, ETC.

121

'shed in the conjunctiva, but is rotainod in tlie coniea*
The pupils remain setijsitive^ and are neitlier contracted nor dilated,
neither are there symptoms of concussion or compression. There are
no vomitings and no contractiona, Tlie pulse is weak and small, and
the temperature rather below the nonnal standartL Occasionally there
are epileptiform convulsions. Psychical troubles do not ordinarily ap-
pear till the collateral circulation becomes active, and local hyperaemia
h thus induced.

The principal exception I have to make to the foregoing sequence
of symptoms is the too absolute assertion of the paralysis of the facial,
bjTpo^iosaal, and other nerves. I have seen several cases in which there
wms no paralysis to be detected in any part of the body by the most
oareftil examination, and several others are on reeortl* In one very in-
teresting instance, occurring in a lady who had had repeated attacks of
ftoote rheumatism, and who had at the time marked aortic iiistifficiency,
liesdache and vertigo suddenly occurred while she was conversing with
a fri*^nd, and her speoch was cut short with as much suddenness as
iliongh she had been shot. There was no paralysis of the tongue, but
eO idea of language was abolished. Within forty-eight hours she re-
coTftred entirely the faculty of speech. In another, that of a gentle-
oimii with a similar clinical history, headache, vertigo^ confusion of ideas,
and amneBic aphasia, suddenly supervened. That both these were cases
of embolism can scarcely, I think, be doubted*

And then, as regards the state of the pupils, my experience does
not coincide with that of ErlenuK^yer, for I have frequently found either
dilatation or contraction of both pupils, or dilatation of one and con-
trmrtion of the other.

lii rtg a case of recent embolism, the ophthalmoscope should

alway I to view the fundus of the eye, and even in old cases

valiiaBle signs >*ill often be obtained. The middle cerebral artery, th©
mifinrj seat of embolus, arises from the internal carotid, after the an-
iHMr cerebral and ophthalmic have been given off. Occlusion of its
dtsnnrl must* of course, throw an increased amount of bltx>dinto these
l4sl-nantc<l arteries, and, as the arteria centralis retinse is derived from
the ophthalmic, it and its branches become enlarged. The ophthal-
nicsoope will enable us to discover the congestion thus produced, and will
often be thu means of helping us to determine, in the absence of pa-
imlysis, wbicb side of the brain is the se^t of the lesion. In older cases
wn wtI' ' iidy find retinal congestion,

Tlu fig case I quote not only as being the first of which I

bjiine any knowUnlgc in which the ophthalmoscope was used in a case
ol ccn*bral embolism, but as being interesting from the fact that the
enboluii was on the right side. It is reported as

C^rehmi Emholhmfolhmng Yalvuktr Disease of the If tart, — John
^^j^VDholl, agicd seventeen, was admitted into the Hull General Infirm-

128 DISEASES OF THE BRAIN.

ary, on April 25, 1867. He was tall, much wasted, and had a suffering
expression, and converging strabismus of the left eye, the mouth being
drawn very slightly toward the left side. Pulse 70, very thrilling in
character, and a large coarse systolic murmur near the left nipple. He
was perfectly sensible, complained of severe frontal headache, with
confusion of vision, and stated that he had been in much the same con-
dition for seven weeks, his illness beginning spontaneously with head-
ache and vomiting, unaccompanied by loss of consciousness or con-
vulsions. He had had an attack of acute rheumatism in the previous
summer. He was ordered gr. iij of blue-pill . and gr. ij of extract of
henbane in a pill, and a draught of acetate of ammonia, three times a
day, and spirit-lotion to the head. " No marked alteration in his con-
dition, except progressive debility, took place till May 2d, when he
complained of increased headache and dimness of vision, and, being un-
able to expectorate, from excessive weakness, death from bronchial
obstruction threatened. With the aid of some champagne, he rallied
in about twenty-four hours, and at the end of a week was much im-
proved, having a clean tongue and good appetite, but the headache, stra-
bismus, and deviation of the tongue to the left, remained. On May 16th
it was noticed that these symptoms had passed off, with the exception
of the last mentioned. He was ordered a mineral-acid mixture.

"A week later, as he still complained of some dimness of sight, he
was examined with the ophthalmoscope. The retinal vessels were
found much enlarged, and the veins very tortuous; the optic nerve-
entrance of an intense red color, not being distinguishable from the
surrounding parts except by the entrance of the vessels, the redness
being chiefly due to a number of very fine vessels radiating from the
centre. There was no morbid effusion in any part. He could spell
easily from No. 15 of Jaeger's test-types (being unable to read and
write). He was again examined at the end of another weejc, when the
optic nerve-entrance was observed to be paler in color, so that its cir-
cumference could be distinguished, but still much injected, and the
vessels nearly as large and tortuous as before; sight was apparently
perfect. He was discharged convalescent.

" The peculiar form of paralysis in this case denoted some morbid
condition within the cranium, wliich appeared to have its most easy
and natural explanation in cerebral embolism, an opinion further sup-
ported by the perfect recovery of the patient. The case received much
additional interest from the information afforded by the ophthalmo-
scope, for one may fairly believe that the intense congestion of the
retinae denoted a similar condition of the brain, perhaps a state of re-
action after the circulation had been re(^stablished through collateral
channels." *

1 BrifUh Jfedical Joumalj 1867 ; also Quarterh/ Journal of Piifeholoffieal Medicine,
January, 1868, p. 178.

PARTIiX CEBEBRAL ANEMIA, ETC.

129

CanSBS* — The most common first step in the causation of cerebral
embolism is acute articular rheumatism, which, by inducing acute en-
inlitisj leads to the formation of emboli on the valves of the heart
other parts of the endocardium. Aneurisms of the aorta or other
largie artory, resulting in the coagulation of the blood in the ancurismal
ocs, may likewise induce it, by a portion of the clot being washed off
by the current, Esmarch * details a case in which, while an examina-
tkm was being made of an aneurism of the carotid, the patient sud-
denly fell back in an apoplectic stupor. The whole right side was at
once paralyzed, the facial muscles on the left side were convulsed, and
fyur days afterward death ensued. Post-mortem eatamination showed
the left internal carotid, the middle cerebral, and the ophthalmic,
completely closed by coagula, which were identical in stnioture
«i*| ;ince with the clot in the aneunsmal sac.

may also originate in tho lungs, and, entering the left

Boricle through the pulmonary veins, finally lodge in a cerebral artery.

Age appears to exercise no influence over the formation of emboli,

but men are much more commonly the subjects than women, for the rea*

lOD, nndoubtedly, that they are more liable to attacks of rheumatism.

Of j«ixty-two cases under my care, either alone or in consultation,
in which I had reason to diagnosticate cerebral embolism, there was
lie flisease of the heart in all but four. Three of the cases were
sixty years of age; seven between fifty and sixty; eleven between
forty and fifty; twenty-nine between thirty and forty; and twelve under
thirty. Thirty-nine were males and twenty-three were females,

DiS^OSiS* — From cerebral ha?moiThage, embolism may bo distin-
goisbed by the following signs. It occurs without relation to age|
wUlfs hjBmorrhage is much more frequent in persons over forty; there
ftre no pcpdromata; the resultant paralysis is generally on the right
fidei while in hfemorrhage there is no such predisposition; and it is in
the great majority of cases associated with organic disease of the left
■ide of the heart. Care, however, must be taken not to over-estimate
tkeinJo/e of this diagnostic mark, valuable as it is. In one case under
0*7 diaige, in which Uie symptoms pointed strongly to the existence
of a rerrbral embolus, and in which, after death, the left middle cerebral
tttery waa found occluded, the heart was perfectly healthy; and in one
^'tk*?!'^ in which cerebral embolus was diagnosticated, and in which there
r»l regtirgitation, extravasation into the corpus striatum was
d to be the cause of death. A case has recently bpen re-
ported by Dr. J. Hughltngs Jackson,' in which there was cerebral haem-
^•Aige with hemiplegia, together with extensive valvular disease of

A patient now in the New York State Hospital for Diseases of the

* ArM^f^ PHttMoffig, Anai<mi* und Phtftidogie, B, xL, Heft 5, 1867,
« BnHth Mt^esl Jimrwil^ October 29, IB 70, p. 4&9.

130 DISEASES OF THE BRAIN.

Nervous System has left hemiplegia, involving face, arm, and leg. It
has already lasted seven months, although greatly improved. The
hand and arm are much contracted. The attack was apparently in-
duced by strong muscular exertion being made while in a stooping and
constrained position. Most physicians will be disposed to agree with
my diagnosis, that the case is one of cerebral haemorrhage, for the
obvious cause of the paroxysm, the lesion being on the right side of the
brain, the steady improvement and the muscular contractions, all point
to extravasation of blood instead of embolus. Yet he is under twenty
years of age, and, before the seizure, had an attack of acute rheumatism,
with heart-symptoms. He now has aortic and mitral regurgitation.
Such cases as the above are very instructive, and they show us how
necessary it is to weigh all the facts, and how great is the possibility
of making a mistake after all. For, although I am inclined to the view
of haemorrhage, no definite opinion can be given without a post-mor-
tem examination.

Still in a case of partial or complete hemiplegia, with or without
apoplexy, in which the patient was below the age of forty, with the
hemiplegia involving the right side, no muscular contractions and or-
ganic disease of the left side of the heart, with or without previous
attacks of acute articular rheumatism, cerebral embolus may safely be
said to be the cause of the symptoms. Moreover, the paralysis from
embolism, if it does not disappear within seventy-two hours after the
seizure, does not gradually fade away as it so frequently does to a great
extent in haemorrhage.

It is a somewhat remarkable fact that in cerebral embolism the pa-
ralysis may be very extensive and complete without the occurrence of
other notable symptoms. Thus in the case of a young lady whom I saw
in consultation with Drs. Polk and M. A. Wilson, there had been in
childhood a severe attack of inflammatory rheumatism and several minbr
attacks subsequently. On the last day of September, 1874, she sud-
denly became hcmiplegic on the left side, but did not lose consciousness.
There was no aphasia, pain in the head, convulsive movements, nor
mental disturbance. The paralysis, however, involved the left arm and
leg, and was exceedingly profound. The face was aifected for a short
time, but the tongue retained its motor power. Three months after-
ward she could stand and walk a little, but was not able to raise the
foot from the ground; the arm was absolutely immovabU. Here the
clinical history, accompanied as it was with a record of heart-disturb-
ance for several years, was such as to leave no doubt as to the lesion
being embolism of an artery — probably the middle cerebral — of the
right side of the brain.

The suddenness with which embolism takes place, to say nothing of
the other points in the clinical history, will suffice for the discrimination
from thrombosis.

PABTUL CEREBRAL ANEMIA, ETC. 131

PrpgnOSis. — ^Tlie prognosis in cerebral einboHsni is gravr, for thu
tmoion ihskt the tendency to softening' of the amBmio cerebral tfssue
Always exists* But, if the patient passes over the first four or five days
wiiiiout aay aggravation of his symptoms, and especially if they ha
mitigated in violence, there is considerable hope of a favorable result.
Stilly a guarded opimoa should always be given till all head*symptoms
hiive disappeared.

Morbid Anatomy and Pathology, — The first rational explanation of
was made by Virchow/ in 1847, who, in his paper on acute
ition of the arteries, distinctly explained the mauner in wliich
tb^ Tfirssela were occluded by clots transported in the blood from dis*
taal parts of the body, and who associated these coagida with valvular
diiease of the heart. In two of the cases cited by him in which arteries
wi»n* found closed by such clots, the valves of the heart wore discovered
to have others still attached to theni, and exhibited traces of the s^-p-
aratioiii of those which were found in the vessels,

Subfwrjunntly (in 1852), Dr. Senhouse Kirkes * called special atten-
liaa to the plugging up of the middle cerebral artery as a cause of soft-
utiiig of the brain. Three cases, in which death followed, are adduced,
io emch of which the condition of uou-inilammatory softening was found
toesdstiii the brain. Dr. Kirkes's observations appear to have been
Qiadc without any knowledge of Virchow's prior roijearches. He states
that tho i»aralysis met with in young persona may be dufi to the inter-
fupttoii of a due supply of nutriment to the brain by the occlusion of
ai^ ' ^ derived from the left side of the heart,

_ / among others, has written with groat fullness on
this subjoot. Among other oonclusions not specially applicable to the
paiticcilar point now under consideration, he states that fibrinous con-
cretiom may form in the heart or large vessels, may subsequently be
deteclied and carried by the blood to the cerebral arteries, where they
produiM symptoms not essentially different from those noticed in cere-
bral lucsiorrfaage or acute soften iug.

Ho otnly material points of difference under this head between
ikromboais and embolism are, the suddenness of the attack, the part of
tbe brain most liable to be affect ed, the origin of the clot, and the state
of '* * ' mI^vcsscI which is obliterated*

Lj to the first, the abrupt closure of a vessel as in embolism
will, of ocforBe, produce more riolent symptoms than if the occlusion

' ** Uglier die Akute En trim dung der Artcrien." ArcMv fur Path/tL Anatomi*, B, ly
I9€?,pi iTS, In ft |>»|H*r ati " Oct'liwlon of the PutmoiiAry Artery," puhlL^hud in FiMrt«p'a
Jtrnt^JTwHafm in 184(1, h«* «^nimciftted & f^tiiiiljir th<.^cir7.

*^Qli WNod of the Principal EU'ecta rt'^uUtng from tbi? DeUehinenC of {•Ibriaoaa
Df^aiili ftvm iIm Iikt«Hor of the Heart, aud their Mixture with the Circuktlag Fluid."
Mfdk^Ckifuryiml Trtmm4gti(mt, vol xxxv., 1^52.

• O^mm 4m B^piimt, Xo. tlO, 1857.

133

DISEASES OF TEE BRAIN.

has taken place gradually, and thus time have been afforded for the
establishment of the coUateral circulation. In the first case, not only
is the blood at once shut off from a portion of tlio brain, but the vessels
beldnd the clot receive a greater quantity than they normally do, and
hence the regions they supply are immediately congested. In examina-
tion of the brain of a person who has died during the first stage of
cerebral embolism, we find those parts of the brain ordinarily supplied
by the obliterated vessel paler than natural, with a zone of congested
tissue, and perhaps numerous small extravasations of blood on the
periphery.

The place where emboU are most frequently found is, as has already
been stated, the left middle cerebral artery. The left common carotid
arises from the arch of the aorta in a line almost exactly coinciding
with the course of the blood-current. It therefore happens that an
embolus which has formed on the lining membrane of the heartv, and
which has passed into the aorta after having been detached, enters this
vessel instead of the innominata. From the common carotid it passes
into the internal carotid and thence with the stronger and more direct
current into the middle cerebral artery, which is lodged in the fissure
of Sylvius. Of forty-two cases of cerebral embolism collected by
Meissner, in thirty-four the left hemisphere was the seat. Of sixty-
two cases occurring in my own practice, and to which reference has
been made, fifty were accompanied with right hemiplegia, and were
consequently on the left side of the brain. Post-mortem examinations
were made in eleven of these cases, and in all the embolus ooeupied the
left middle cerebral artery.

Of these latter was the caso of a prominent elderly gentleman of
Providence, Rhode Island, whom I was requested to visit in consul-
tation with Drs. Parsons and Collins, of that city. Three days be-
fore, while ascending a hill, he had suddenly become semi-unconscious
and hemiplegic on the right side. There was also well-marked aphasia.
When I saw him he was in a state of partial coma, from which he could
be roused so as to be made to comprehend, but was unable to talk,
and was entirely paralyzed in the face, arm, and leg, of the right side.
The clinical history indicated the existence of disease of the left side
of the heart. I diagnosticated an embolus of the left middle cerebral
artery, and expressed the opinion that death would ensue within a few
hours. In both of these views the other medical gentlemen fully con*
cujred. The patient died about eight hours afterward. The post-
mortem examination was made the following day, and proved the
correctness of the opinion that had been expressed, for an embdiia
completely occluded the left middle cerebral artery, at the point whore
it divides into the branches which supply the island of Reil and the
convolutions of the base of the anterior and middle lobes.

The pathology of the genesis of the clot has already been sufEciently

PARTIAL CEREBRAL AN.EMIA, ETC.

It upon in other connections, and the fact that the arteiy in wMoh
il tft found is not diseased has been mentioned*

The farther consequences of embolism belong to cerebral sof tening*,
snd will be considered under that head,

Troatment. — It is not necessary to make any remarks on this point
in addition to those made in regard to the treatment of thrombosis.
There is very little to be done besides meeting' indications as they
arise, and attempting to relieve the paralysis and other symptoms, for
which ends my riews have been sufficiently expressed in the preceding
chapters.

ni. — ^TBROMBOSIS OF CEHEBBAX. VEINS AND SINrSES.

It was, until the researches of Virchow, generally supposed that the
coagTiIation of the blood in the veins was the immediate result of
phlebitis; but through his investigations it is now very well understood
that, in the great majority of cases, the inflammation of the veins is a
consequence of the formation of a thrombus, and not a cause. For
reasons which will be given further on, the sinuses of the dura mater
are especially liable to be the seat of autocthonous coagulre.

SymptoniS, — It is very doubtful if venous cerebral thrombosis pos-
Kflsee such a characteristic symptomatology as to admit of its being
identified during the life of the patient. Tlicre are headache, convul-
epileptiform in character, paralysis of different parts of the body,

ioularly of the ocular muscles, giving rise to squinting and double
Tiaton, disturbances of sensibility, and, toward the close of the disease,
Occasionally there is apoplexy at an early stage.
i.in symptoms have been laid down by authors as indicative of
the erifitence of thrombosis of particular sinuses. Jaccoud,* however,
appears to discredit their importance, and I am disposed to agree with
him that, though it may be well to know them, it is safer not to attrib-
ate to them an absolute value, llius, Von Dusch * asserts that epistaxis
is aytnptomatic of obliteration of the superior longitudinal sinus ; Ger-
hafdt ^ finds a difference in the size of the external jugular veins — ^that
of :* * 1 side being more collapsed than the other — indicative
of r the lateral sinus ; Griesinger* states that the presence

of a painful circumscribed oedema beliind the ear is evidence of the
ejdsteiice of thrombosis of the transverse sinus extending into the veins
whicti lead to the sigmoid fossa; andCorazza* thinks obliteration of
tbo aaperior longitudinal sinus is signified by oBdema of the frontal

• '•IVaSU" '■• r^y inlerne/' tome pmnier, PaHi«, 1870, p. 149.

• Hcaleiiii ; **2tit*chrift fiir ration. Meclicm/* ft. vii,, 185», p. 161.
ICav BfinAtm Translation—^' On Thrombosis gf the Cercbfal Bixtusoi)" Londoi

* Ikm/mkf KUmk, 18&7, Xa 45,

* ** BMUc^lmiecn ueber Himknakhdten," ArMv itr BtBbmik^ Idea,
•^-R^flilaCUmea/lSCe.

Alsoiha

134: DISEASES OF THE BRAIN.

veins, and exophthalmos. An important point in the symptomatology
of thrombosis of the encephalic veins and sinuses is the often simulta-
neous presence of suppurative inflammation of the ear. This is ex-
plained by the fact that the relations of the mastoid cells and the
petrous portion of the temporal bone to the lateral, the cavernous, and
the petrosal sinuses, are so intimate that the extension of a morbid
process to them, from the parts of the cranium in question, is readily
accomplished.

Owing to the inflammatory action so frequently set up in the vein
or sinus in which a thrombus has been produced, pus enters the gen-
eral circulation, and hence abscesses are liable to occur in distant parts
of the body.

In the very interesting case which forms the basis of Von Dusch's
important paper, the principal phenomenon observed during the life
of the patient — an infant nine months old — ^was a large abscess
occupying the anterior and outer portion of the right thigh, from which
half a pint of pus was obtained, by incision, and which continued to
discharge for several days. Death occurred in a few days •without
being preceded by convulsions, coma, or other head-symptoms. On
examination after death, the anterior part of the superior longitudinal
sinus was found to be completely closed by a firm, pale, triangular clot
of blood, adherent to the wails. Posteriorly the clot did not entirely
fill the calibre of the sinus, and was softer. Similar clots were also
found in the left lateral sinus, and in the veins terminating in the
superior longitudinal sinus.

In a case reported by Abercrombie * as " Suppuration within the
Left Lateral Sinus," the affection undoubtedly resulted from an exten-
sion of inflammation from the cranium to the veins. The patient, a
young lady aged sixteen, complained of severe headache, which ex-
tended over the whole head. She had an oppressed look, and great
heaviness of the eyes; pulse 120; tongue clear and moist; face rather
pale. She had been liable to suppuration of the ears, and the left ear
had been discharging pus for three weeks; had complained of head-
ache for a fortnight. A few days afterward, her strength began to
fail, there was a tendency to stupor, and slight delirium was present.
There was constant complaint of pain in the head. Finally, she became
more comatose, but was sensible when roused, and knew those about
her- a few minutes before her death.

On post-mortem examination the membranes of the brain were found
congested, but the brain-substance was not diseased. The left lateral
sinus was inflamed throughout its whole extent. '^ Its inner coat was
dark-colored, irregular, and fungous. At one place the cavity was
nearly obliterated. The disease extended into the torcular Heropluli,

* " Observations on Chronic Inflammation of the Brain and its Hembranes.*' JSUtn*
burffh Medical and Surffical Journal^ vol. xiv., 1818, p. 288.

TARTIAL CEREBRAL ANEMIA, ETC,

135

mad allcctLcl a, Uttle the terniination of the longitudinal sinus» Behind
ibe auditory portion of the temporal bone, near the foramen lacerum,
and in the course of the left lateral sinus, a portion of the bone nearly
the aize of a shilling was dark-colored and carious on the inner table,
It was at this place that the sinus appeared to be most diseased/'

It is stated that the walla of the sinus were so thieketied as to pre-
Tcnt tfie passage of the blood, and that evidently no blood had trav-
ersed it for some time. Although Abercromble failed to recogidze the
real nature of the morbid process, there can be no doubt that the sinus
was closed by an old coaguium, which had been adherent to the walls.
Prichard* reports the cas« of a girl sixteen years of age, in whom
I •iflgptio coQVulsions had existed for two years, and recurred very fre-
f^fWillyf sometimes several times a day. There appeared to have been
tii> other symptoms indicating cerebral disturbance except that it is
meDilaaed that at one time she was slightly delirious, and then was
freo from fits. She was treated actively for nine months, and then died
in A c t^ of the usual character.

Ex »[i after death showed that *'the left lateral sinus, through

its whole extent, was fiEed up by a substance very different in its
naitife from a recent coagulum, and apparently consisting of a deposi-
tiiMi of lymph^ which had become organized. It appeared so com-
pletely to occupy the calibre of the sinus as to have entirely Impeded
llie passage of the blood through it.^^

Another case, reported by the same author,' is that of a girl twenty- ,
two y«kW of agCj whose mother had been insane, and whose complaint
** b«gmii by a feverish disorder, under which she labored about nine
weekft. It was followed by a melancholy and pensive habit. She was
observed to spend most of her time in reading religious books, and
attended a meeting of Calvinistio dissenters. '' When she first came
under treatment, her appearance was very wild; she was mischievous,
:id of destroying her clothes. Ih about three months and a half
discharged cured, but was readmitted a month afterward, and
aed in the hospital tiU her death, wliich took place about tliree
I subsequently. During this period her constitutional tendency to
tGfofula showed itself in a decided manner. The glands of the neck
wvro CrtKjaently swollen and inflamed, and she was repeatedly attacked
by pnetiniomo symptoms. When these disorders became a little
iciieTed, her mental alienation was aggravated. She generally sat with
' hatkds folded, and her eyes fixed downwarcL She died from general

iity^ mnd exhaustion, but without additional head-symptoms,
Po«t*mortcra examination revealed the existence of thickening of
dara raater, serous effusion between this membrane and the pia
, duid within the pia mater, and thickening of this membrane,

* ** X TreatUe oa Pidosses of the Nerroas Syatem/* Loadon, 1832, p« HG.

136 DISEASES OF THE BRAIN.

The substance of the brain was very firm, the pineal gland was large.
*^ The longitudinal sinus contained a firm coagulum, resembling a poly-
pus, which extended into the lateral sinus.'*

In only one instance have I had the opportunity of making a post-
mortem examination in a case of thrombosis of a cerebral sinus. The
patient, a man forty years of age, had been upon a drunken debauch
for several days, when he gradually passed into a condition of stupor,
which was at first mistaken for the continued effect of alcoholic intoxi-
cation. As it continued for two days after all stimulants had been
withheld, this idea was abandoned, and the diagnosis of cerebral
haemorrhage was made. I saw him at this time, and was disposed to
agree with this opinion. There were profound stupor, stertorous
breathing, and complete resolution of all the limbs. Much to my
surprise, however, the state of coma gradually passed off, and as sensi-
bility returned the patient complained of intense pain in the forehead
and vortex, which was accompanied by twitchings of the muscles of
both sides of the face, and of both upper extremities. On the tenth
day right hemiplegia suddenly ensued, unattended with loss of con-
sciousness, though there was a slight disposition to stupor manifested as
soon as the attention failed to be engaged. The pupil of the left eye was
dilated. On the twelfth day a severe epileptiform convulsion ensued,
which was succeeded by another on the same day, during which the
tongue was very severely bitten. Control of the bladder and rectum
was now lost, and on the fourteenth day the convulsive state became
permanently established, and the patient died that night without
regaining consciousness though the convulsions became somewhat less
violent.

The post-mortem examination was made the following morning.
The pia mater and arachnoid were somewhat congested, though the
subarachnoideal fluid was not notably increased in quantity. The sub-
stance of the brain was healthy, and there was no extravasation of blood
anywhere to be found. But, on laying open the longitudinal sinus,
a firm coagulum was found completely occluding it, from its bej^nning
anteriorly, to its termination in the torcular Herophili, partly filling
this cavity, being attached to its anterior wall, and extending for the
distance of an inch and a quarter into the left lateral sinus. The
thrombus was much more dense and compact in its anterior than in its
posterior part, and that portion which occupied the lateral sinus was
evidently of more recent formation than the rest.

A consideration of the symptoms exhibited by these cases wil\ serve
to show the truth of the assertion made in the beginning of my
remarks on the subject, that there are no such characteristio symptoms
of thrombosis of the cerebral sinuses as will suffice for the identification
of tiie disease. The most that can be premised is a not very decided
probability.

PARTUL CEREBRAL AN^MU, ETC.

137

i — AnioDg the causes of thrombosis of the cerebral veins and
se affections of the heart iu which the force of its systole
is lessened, and those in which there is an obstacle to the return of
the Tenous blood, occupy a prominent place* Through the action of
eitlier of these categories of diseases the circulation within the ci-anium
is retarded, the blood tends to accumulate in the large veins and
sliutses, and, its course being abnormally slow, coagulation is liable to
€fi8tie« Tumors in the neck, by compressing the internal jugular veins,
aba tend to the same result by backing up the blood in the lateral
iitms. An intra-cranial tmnor may exercise a Hko effect by direct
pressure upon a sinus.

Thrombosis may result from the extension of inflammation from the
cranium or the cerebral tissue to the sinuses. Such is the case when the
8U{>puration of the ear terminates by the formation of a thrombus in
tbe lateral, cavernous, or petrosal sinus, or when abscess of the brain
or SB extravasation of blood produces a like effect. The condition in
question may also be caused by injuries of the skull; it has been known
to follow the operation of trephining and other surgical procedures on
lite cratuuni. and may also result from oarbuncles, of or near the head,
itid itom erysipelas occurring in like situations.

jlffe appears to be of some influence as a predisposing cause of
wious cerebral thrombosis, Tims, of thirty-seven cases cited by Gin-
tiac,' fourteen were between the ag^s of three weeks and ten years,
eleven between eleven and twenty years, six between twenty-one and
tbirty years, four were forty-five, fifty-five, sixty-five, and sixty-eight
years old respectively, and two were of advanced age, not exactly
Imown. As Gintrac remarks, the first period of Hfe is that which is
moat faTomble to the occurrence of venous cerebral thrombosis, adoles-
eenoe and adult age are a little less favorable, and old ago is the least
80of alL

^SSfSS seems to be of no predisposing power: of thirty-one cases in
tiio sex was stated, fifteen were males and sixteen females*

Pttl|ffiOSis» — ^The elements for fonniiig a prognosis being of a very
imltftertiumite character, it is difficult to form an opinion relative to
tlte (tft^able result iu the ease of a person presenting the symptoms
which have been mentioned. It is perhaps, however, warrantable to
saj that thrombosis of the cerebral veins or sinuses must from the very
oatmo of the lesion be a most grave disorder, if not one necessarily
iital, fioofier c>r later. If the vein or sinus in which the clot exists be
sntally and if the causes be of such a character as to admit of removal|
And thus the extension of the coagulation be preventable, the prognosis
wotild of course be more favorable than if an opposite state of affairs
After all, the only data from which a judgment can be formed

the sererity of the symptoms and the course and duration of the

* Op, el loe. eit^ p. 52S.

■ so of I

138

DISEASES OF THE BRAIN.

disease. The symptoms themselves can be of very little service in this
respect, for, as we have seen, they have no such pathognomonic value as
to indicate to us the pathological coiiditioii vvnth which we have to deal
Diagnosis. — After the remarks already made incidentally with ref-
erence to this point, there is nothing to say which can elucidate the
subject.

Morbid Anatomy and Pathology*— The ordinary seat of the a^ection
tinder Gonsideration, when not the result of some other oontigaous
lesion, is the superior long'itudina! sinus ; when due to suppuration of
the ear, the clot is usually first found in the lateral sinus ; when resulting
from injury, it has a near topographical relation to the seat* Thrtjugh
the occlusion of the sinus it becomes distended on the distal side of the
clot, and the blood is thus thrown back upon the capillaries and ovcntu-
ally upon the arteries. A state of cerebial ischiemia is therefore in-
duced, to which the symptoms of the first stage of the disease are, in the
main, to be aseribed« lliis ischiomia may lead to extravasation of blood,
to inflammation, or to softenings. An increased effusion of serum into
the sub-arachnoid space and into the ventricles is an almost neces-
sary consequence. The clot differs in character according to its age.
When recent, it is soft in consistence and almost black in color, and is
not adherent to the walls of the sinus in which it is situated. MTien
old, it is grayish, dense, and unresisting, and attached to the wall of
the vessel. If it be divided, a soft, broken-down mass is often found
occupying the centre. This consists of fat and other elements of the
regressive metamorphosis which the substance of the thrombus has
undergone. It was undoubtedly this matter which Abercrorabie and
other writers mistook for pus.

Other points in the morbid anatomy and pathology of venous cere-
bral thrombosis have been suJHciently conbidt^red in the remarks which
have already been made.

Trdatment* — ^There ar^ no means at present known to science by
which the affection can be cured, or its consequences prevented. AU
that can be done is to treat the symptoms as they arise, to search for
their cause, and to remove the latter if removal be possible. Life mar,
in some cases, be prolonged by the Judicious use of quinine and stimu-
lants. Convulsions may be lessened in force and frequency by the em*
ployment of the bromides, and pain assuaged by hypodermic injections
of morphia, by a pill containing half a grain of codeia, given at bed-
time, and repeated if necessary, or by directly taking off a part of the
intra-cranial vascular tension by leeches to the inside of the nostrils^ or
cups to the nape of the neck.

4
4

rV.— EMBOLISH AKD THBOSiIBOSIS OP THE OEEEBBAL CAFILLXRIKS.

The capillaries of the brain may be occluded either by embolism or
thrombosis, as arc the larger vessels. But the phenomena of these

^^^

PAETUL CEREBRAL AN^MU, ETC.

139

indefinite and obscure that it is impossible, in the present
Lnowledge, to identify thein during the lifetime of the sub-
Joct, There is, therefore, little to be said relative to partial cerebral
attiemiii resulting from obstruction of the blood in the capillaries, other
tluui to call attention to the genesis, the morbid anatomy, and the
piaiboIogY of the processes in question. It will, accordingly, be more
oaDvenient to consider the subject without subdivision into symptoms,
€MiM0» etc.

Khbolish of the cerebral capillaries may be the result of deposit
of ffif^ment^ ot fat^ oi pus^ or of the debris of various tiiHufS^ normal or
abnortnaly which have undergone decomposition.

Pigment may be deposited in the capillaries "whenever the blood —
is it does in certain diaeases^ — contains an abnormal amount of pig»
mentsry corpuscles, Meckel* appears to have been the first to call
sttcDtion to the condition in question. In the case of a lunatic, he dis-
covered the spleen to be enlarged, and to be covered with dark pig-
tlUiiit. Virchow' soon afterward, in the case of a patient who had been
subject to ague, found the spleen enlarged, black, from excess of pig-
ment, and the blood in the heart to contain cells with pigment. Meckel
attributed a great degree of importance to the occurrence of mehxna?-
mia — as the blood-disea,se is called — for the reason that he considered
the pigmentary obstruction of the capillaries a condition liable to result
tiitfrefroni, and, as a consequence, when those of the brain are thus af-
fected| the supervention of head -symptoms, Virchow*, however, w^hile
siiiDittiiig the possibility of such a sequence of phenomena, is not able
to add any facts tending to elucidate the subject.

Frurichs* has called attention to the pigment liver as associated
wi fitary emboli in the capillaries of the brain. Thus he says:

**'i .{ organ in point of frequency to the liver, which undergoes

importiint organic and functional derangements, is the brain. Numer-
oun particles of pigment, which have passed unarrested through the
vessels uf the liver and the lungs, accumulate in the narrow capillaries
of thia organ, and particularly in those of the cortical substance. Even
by simple inspection of the shade of color, we can form an approximate
Dotion of the quantity of eoloring-matter which has been deposited, and
of the extent of the vascular obstruction. We must not, however, rely
eoUrt-ly u|Kjn inspection, for alight accumulations of pigment in the
Oipinsffies easily escape notice^ particularly when viewed with an nn-
eye, and can only be distinguished with the assistance of the
ipe. In addition to the above, it is not at all uncommon for the
Is to become obstructed by a colorless fibrii)ous*Iike coagulum
^^^Aioh of course does not affect the shade of oolor* The mechanical

^^V M§, Ztiitthrtft/ur P^i^iairie, 1 8i7, cited by Tirchow. ** Die CuUular.Pathoio^ev"
^^Bih^ ISTl, p. 263, Mid Jaoocmd, cp, eit., p. 144. * Op, dt

^^H^ **dfaiik dsr Lcberknmklielttiti," Sydenham Sodety Tmnalatioa, vol i, p. 814,

140 DISEASES OF THE BRAIN.

interruption to the circulation which is produced in this way, not
unfrcquontly gives rise to rupture of the small vessels, and the forma-
tion of numerous capillary apoplexies. Meckel long ago made observa-
tions of this nature. Planer described eight cases in which famall ex-
travasations were scattered through the gray and white substance of
the brain. These numerous hsemorrhagcs have not come under my own
observation ; but in two cases I have observed extravasation into the
meninges."

Freriohs states that he has seen three cases in which there were
functional derangements indicative of material changes in the cortical
substance of the brain. One of them was that of a lady in her fortieth
year, who, after an attack of quotidian fever, accompanied by somno-
lence, suffered from protracted loss of memory. The functions of vege-
tative life resumed their nonnal condition, and there were no derange-
ments of motion or sensation present. The headache and giddiness
gradually diminisheil after the removal of the intermittent fever, by
means of quinine ; but the weakness of memory, and the inability to
find suitable words for objects and ideas, were still on the increase two
months after the cessation of the ague.

Another case was that of a girl, aged nine years, living in the same
district, where, according to the evidence of two medical men, iatermit^
tent fever, tenuinating fatally, was at the time very prevalent. This
girl, whose mental powers had previously been normal, had ui|deigoiie
several attacks of tertian fever. After a protracted use of preparatioiis
of bark, she recovered in her bodily symptoms ; but her mental fuiil-
ties gave way, and a state of complete idiocy, accompanied by a imTea-
ous appetite, suporveneil.

In reganl to these cases, Frerichs further remarks that it is on-
certain whether atrophy of the brain had resulted from occlaaon of the
capillaries, or whether it had been induceil by the estensire capQIaiT
apoplexies consequent upon this occlusion, or whether the intennitteat
fever was complicated with other accidental changes in the braiii. He
gives the details of several other cases of intermittent fever, acoompa-
nied by head-symptoms, and in which, after death, the cerebral cifiilb-
ries — principally those of the cortical substance — were occladed by de-
posits of pigment, originating in the liver and spleen, and trmnspcitcd
to the brain by the current of the circulation.

A case is roportevi by Bright,* of a man, who died of paralysis fol-
lowing fever, in whom the cortical substance of the brain wms tlie rakr
of black-lead.

Sydenham had not failed to notice the fact tliat m^itai desuge-
ment sometimes remains after intermittent fever, wbic^ if t2«ated If
depletion, passed into imbecility.

Cases of Uke character have frequently come under iwr iftosiee. Ii
> ** Reports oni«£ctl Cases,** London, ISOl, cbapler ci, ]

FARTUL CEKEBRAL ANEMIA, ETC.

141

one of these there had been repeated attacks of intermittent fever, and
the S|ile<*n was greatly enlarged. The patient, a yoting man twenty-
El two years of age, had suffered from epilepsy for several months, the
^^pl paroxysm ensuing shortly after a severe seizure of fever, and being
^^^pceded by headache, vertigo, confusion of ideas, and twitching of the
■tascles of the face. When I first saw him his miod was considerably
impaired, and he was having three and sometimes four or five epileptic
filA every week. All his mental symptoms were improved by the use
^Arseiiie; his fits ceased, and his spleen became much reduced in size.
» Those physicians who have practised in malarious regions can
rly have failed to notice the fact that the enlarged livers and
PUS, which are so frequently produced by repeated febrile attacks,
iim oft^u coexistent with cerebral s}Tiiptoms, such as have been de-
•cribecL*

The TOfisels of the cortical substance appear to be more liable to oc-
dufioti from pigmentary emboli than any other part of the brain. Some
reoenl researches of my own would seem to show that the vessels of the
reliaa are abo apt to be so obstructed, and that some cases of pigmen-
taiy deposit in the eye are in reality instances of pigmentary embolism
of the intraocular vessels.

Although the ift/mptoms of the affection in question have nothing
'*out them, yet its existence may be suspected with some
>t ^ I'llity, when pain in the head, delirium, cou^nilsions, ver-

tigo, pafuijsis, and other disturbances of sensibility and motility, coexist
with eolaig^ spleen or liver, and when there is the previous history of
mahmal f erer,

Etnbolxsm of tlie cerebral capillaries from migration of Jttt is a con-

dilioo whieh certainly occurs, but w^hich has not as yet been very

ihofonghly studied. Todd,* in a woman who died comatose and hemi-

ple»gic, found after death an extravasation of blood into the right corpus

stiiatum, and that ** the vessels of the softened portion of the corpus

stnalutn. Immediately surrounding the dot, were thickly studded with

oQ-globalefl, which in some situations were aggregated into dark masses

_lplw3jiiai hero and there almost to fill up the vessels. The minutest

i well as the larger arteries, exhibited these deposits, and few

I h< discovered without them,

fcrgmann,' who has devoted much attention to the subject of fat-
ubcJiioi, has recently * reported a case in which a man, who died in
^BBMqaaiioe of injuries received from a fall, was found to have many

'i fiuffbtir ecKMtdetntioQ will ht gircn to llib rurj intereating subject In the forthcora
r of ti»e •nthor, cm " I*ijriuttirnry Ccrebml Eoibolwin, And other Affec^ous of
» System the Results of 3!aljiria! Poboning/*
'^'CUnkal Lecturer," London^ 1861, p. 73S.
I *«2ttf Lchre toij tier Fctt<?rabo1ie." Dorpat, IMS.
' ••♦Da F»n todUcber FettemboUe." Berlins kliniacJu Wo^ientchrift, Ko. 83, 1878,

142

DISEASES OF THE BRAIN.

Uafmorrhagic extravasations into the langs, and numerous oil -globules
in tho pulmonary capillaries. The brain does not appear to have been J
examined, but probably the cerebral capillaries would have been found
in a like condition.

In order to throw additional light on this subject, I have performed
a number of experiments upon animals, of which the description of one
will be sufficient, as the results were analogous in all essential respectSw '

Into the left ventricle of the heart of a medium-sized dog sixty min-
ims of olive oil were injected.^ The animal was killed six hours after-
ward by section of the metlulla oblongata. Tlie brain was removed 1
from the skull atid carefully examined. The membranes were decidedly
congested. The arteries of the base of the brain cootaiiied numerous oil-
globules, and this was especially the case with both the middle cerebral

fw, 17.

Fto. U

attcrirs ' ' minute terminal branches ot these vessels were filled withJ
fat, and : \ i il of them were entirely occluded. The microscope showed!
the capillaries throughout the brain, both of the cortical and medullary
substance, to be gorged with fat-globules, aggregated in masses, so %S
to prevent, in many instances, the passage of the blood.

In other experiments I allowed a longer time to elapse before kill*
ing the animals, and in one death took place spontaneously during ;
state of profound coma. The post-mortem appearances were mor
strongly marked, and in the latter several centres of incipient softening
had been set up.

' The he&rt was penetrated tbrough the tlioracic wall by the needle of an hvpcHjcrmic
tjriage, uid the hyection miule very slowly. The left ventricle was chodea in ankr Ui
aroid, u far as possiblf, the stoppage of the oil in the lungs.

PARTIAL CEREBRAL ANAEMIA, ETC.

148

f
I

Kothiog is known relative to the aymptomatology or pathology of
fkt-c^mbolism of the cerebral capillaries, or of the elements of a correct
diignosis or prognosis of the aileotioti.

The cerebral capillaries may be obliterated, as Virchow * has shown,
by deposits of pus or of the debrk of organic structures undergoing
^aintegnition* Thus a thrombus undergoes such a transformation that
a l^ariform mass originates in its centre through changes taking place in
tbo central layers of the clot, and the whole eventually becomes con-
Tectod into a tinely-granular substance which is capable of being trans- *
potted to distant parts of the body and occluding the smaller vessels
and the capillaries; or, for instance, ulceration following endocarditis
takes place in one of the cardiac valves, as a consequence of acute or
nhroaic softening. The minute fragments of the valve are carried away
bj the current of the blood, and are deposited in the vessels of remote
parts, such as the eyes, the brain, the kidney, and spleen. The accom-
paojring cuts (Figs, 16 and 17) represent these capillary emboli in the
pemetllii of the splenic artery, following endocarditis. In Fig* 16 the
?ea«els are magnified ten diameters j in Pig. 17 three hundred.

Whether such emboli are capable or not of transferring specific di^
aate to other parts where they are deposited, or whether, as some authorsj
dtf«rifig from Virchow, assert, they merely act in a mechanical manner,
U as yet undetermined. The weight of evidence appears to favor the
Ticw of Virchow, that they act not only by occluding the capillaries,
bat also by their inherent specificity originating new centres of local

TasoMBOSis. — ^Thrombosis of the cerebral capillaries may, like the
I ooodition of the larger vessels, result from any cause capable of
hwltieiiig a stoppage or retardation in them of the circulation of the
bk^odi One of the most common of these factors is calcareous deposit,
a ilat« which is only to be detected after death, and which, like many
otber aadbgous morbid processes, was firat clearly pointed out by Vir-
ebow.' According to Iiira it depends upon the failure of the kidneys to
exeneie the mineral matter which is taken up by the blood from the
booaOi and which in consequence is deposited in other organs.

Soma authors regard calcareous deposit as being a process more anal-
ogous to embolism th&n to thrombosis, but it must be recollected that
tbe mifieiiLl substance is not in a morphological state in the blood, but
If b«lJ in solution up to the time of its separation at tl»c places where
il is foafid* It would, in my opinion, be equally logical to regard the
depo«itian of fibrine upon the internal coat of a vessel as embolism,
lor it ia held in solution till it becomes attached to the wall, and in this
laipect does not (Uifer from the condition of the calcareous matter.

> "Dk C^Uukr-Patholofie,** Berlin, 1871, p. 2St, af 9t^,

144

BtBEAEES OF THE BRJLIK.

In the first place, the serum of the blood holding the mineral sub-
stance in solution is probably infiltrated through the vascular walls in-
to the peri-vascular tissue and the deposition effected there. Eventual-
ly, as the change in the surrounding substance tends to prevent further
transudation, and as the vessels degenerate from their normal struct-
ure, the metastatic deposit is made around their internal circumference
and the channel is finallj occluded. At the same time the capilljuies
lose their elasticity and become hard and brittle, Tlie brain in the
vicinity of these centres of morbid action may be so saturated with tho
oaloareous matter as to give a distinct grating sound when cut, and ih^
molecules of phosphate or carbonate of lime may even be seen with the
naked eye and distinctly felt when a portion of the brain is rubbed
tween the fingers.

Marc6 * reports the case of a man, fifty-five years of age, wlio died
a state of complete dementia. On post-mortem examination the mem-
branes were found adherent to the brain; in the centrum ovale of both
sides there existed large lacuuiB of a yellow color and with the appear-
ance of elder-pith* In aiklition, there were numerous calcareous incrus-
tations forming sharp protuberances and giv^ng a sensation to the finger
like that experienced when the tongue of a cat is gently rubbed. The
capiUaries were likewise inerusted* The cerebral substance contained
several old hi^morrhagic /liyer^. The calcareotis concretions were found
to consist of crj'stallized carbonate of lime and of the same substance in
globular masses. Subjected to the action of dilute hydrochloric add,
they were dissolved with the evolution of carbonic-acid gas; an organic
substance analogous in its characteristics to the corpora amylaceji re-
mained; it was not, however, colored blue by iodine.

The capillaries surrounding these masses had undergone^ various de-
grees of calcareous incrustation. On some, the crjrstals were scattered
hero and there on the walls ; on others they formed groups nr plaque^
more or less enveloping the circumference of the vessel. There were
some in which the channel was entirely obstructed by the colorless crys-
tals, without any other foreign matter, fatty, granular, or pigmentary,
being present.

Thrombosis of the cerebral capillaries may also be the consoqtieoce
of atheromatous degeneration and of moniliforra dilatation.

The white substance of the cerebrum, the cortical layer, and the coi^
pora striata are more liable to be the seats of this process than the
other parts of the encephalic mass.

iTOr fl

' "Bulletiu dc la sodM ftaatotnlque/' 186S. p» 458, cited by Qintrac, op. at, p.

CEREBRAL SOFTENING.

145

CHAPTER VL

CSRSBRAL sorrsjriyG.

As a consequence of se%"eral of the conditions described in the fore-
gubg pages, and especiallj as resulting from thrombosis and embolism
8 forms, cerebral softening naturally comes next in oi-der
,tion. Most authors treat of it in direct connection with
obfiii^ration of the cerebral arteries; but, although frequently duo to
litis oiius(.% it may be produced by others, and occlusion is not always
Mowed by softening. For tla^se reasons I have preferred to consider
Hwit really is, a distinct pathological condition — ^aa much so as sclero-
sb or any other morbid anatomical state.

Symptoms. — When softening is the result of haemorrhage, of arterial
inDbolism, or of arterial or venous thrombosis or embolism, the 8>^np-
tam peculiar to those affections .are first met with. Thus there are
trotiblos of the intelligence, the sensibility, and the power of motion,
mc\x Its have already, been described under the heads mentioned, and, if
the rourbid process goes on within the cranium to its full development,
thcw uo peculiar aggravations and the evolution of new s}^ttptoms.
It ComA bus existed from the beginning, it may continue ^nth little or
00 reiin«sion, and the patient may die without regaining consciousness,
wmayh^^come only partially sensible. The condition of softening is
ooi asuaUy set up after either haemorrhage, thrombosia, or embolism,
**ll iboat the tenth day, though some cases are more rapid •in tlieir
pJogwa^ and the sjTnptoms now to be mentioned are those which are
OQUKldeDi with what some pathologists have designated the "second
«^;'' the **yc4luw softening'' of others. The 'Mirst stage," or '*red
***ft<ujia^ " of tbese writers, is, in my opinion, not in reiUity softening,
'^t tiiher the congestion due to overaction in the collateral circulation,
' ' m to the continued paralysis of motion and the loss of
iiich exist on one side of the bo<ly, the mental s^ninptoms
'»^ootiie more strongly marked. There may be delirium with the occur-
'**>^ of hallucinations and delusions, though these are generally eva-
^''•Ciiii, Oocasionally a fixetl idea obtains possession of tho patient's
^'^^ and for a while influences him in his conduct, but his mental
^*»city is not strong enough to enable him to retain it for any length
°* tiftus »o it «oon yields to another.

Hie I " uv.e is nntably diminished, so that the patient is unable
^^ cao(v , iiact idea of Ids situation, or to obtain a moderately

*^^ete notion of quite simple matters which may be submitted for
WiniPtitml action. Thus he refuses to credit the assertion that he is ill,
feUi«i that his healtli, both in mind and body, is excellent, and that
10

146 DISEASES OF THE BRAIN.

he is fully capable of transacting his business or of performing any
intellectual operation.

The memory is invariably impaired, and things of the greatest
familiarity are forgotten. Thus a patient laboring under cerebral soft-
ening, the result of embolism, could not tell his wife's name, nor by
what means he came to my office. Another, sent to me by Dr. Michel,
of St. Louis, in whom thrombosis was the probable cause, could not tell
me where he came from, nor the names of his children. He insisted
with great vehemence that he was perfectly able to attend to his ordi-
nary business, and yet was unable to add three numerals together.

In another case, likewise having the clinical history of thrombosis,
which I saw in consultation with my friend Dr. J. W. Ranney, of this
city, the patient, a gentleman of about sixty years old, could not tell
his age; declared that Dr. Ranney, whom he had known for many
years, was a grocer, " who lived around the comer; '* and held to the
delusion that his sons had made several forcible attempts to rob him.

The power of giving the attention to subjects is very greatly lesB-
ened. The patient may seem to be listening to what is said, or observ-
ing what is passing about him, but, if he be questioned he at once
shows that he really has not been heeding ; even, when things are for-
cibly brought to his mind, and he is told to mark them, he is incapable
of doing so to any considerable extent.

The speech is almost invariably affected either in the form consti-
tuting aphasia, or from paralysis of the tongue and other muscles oon-
cerned in articulation. There is a disposition to misplace words, or to
clip them by cutting off the last syllable. Thus a patient reading tli»
title of i book in my library called it the " Unit. Stat. Dispenst." lo^
United States Dispensatory; another was the "Philosoph. as AbsoL^
Scien." for Philosophy as Absolute Science; and he told me he was **^fc.
lawy. by professi.," when he meant to say he was a lawyer by proles* —
sion. The same fault is shown in reading from a printed page, and Iks
writing. Only a few days ago I received a letter from a genUeman, xm
which the final letter of nearly every word was omitted. The emotioni^^
especially those of a sorrowful character, are very easily excited, an.^1
therefore the least untoward event causes the exhibition of feeKng^.
Sometimes the patient sheds tears without being able to assign mxm^
cause, or may get into uncontrollable fits of weeping; occasionally of
laughing.

All these symptoms indicate failure of the mental power, but it ifl^
nevertheless, true that softening of the cerebral tissue may exist with-
out the manifestation of the least degree of imbecility. It not unfro-
quently happens that, while there is a general loss of intelligence, somo
one or two faculties of the mind are notably increased in vigor.

I have a patient now under my charge whose intellectual force ii
greatly reduced, who cannot pronounce the simplest sentence correctly,

CEREBRAL SOFTENING.

147

paralyzed throughout the? wholi? of one side, and who has so
ise of propriety that if he feels the desire to urinate he yields
td it at once, no matter where he may be or who are present, but whose
rolitioual power is even greater than before the accession of his disease.
Thus he will read volume after volume, turning over the pages regu-
larly, and scarcely, except by oversight, skipping a wonl, although it
is very certain he does not comprehend a tenth part of what ho rcadS|
iml ihjit what he does for a moment understand is immediately far-
gotUjtu Tlie strength of his will is also shown in the impossibility of
inducing him to do any thing which either caprice or habit prompts him
aoi to do. His appreciation of harmony has become so sensitive that a
dboonl of sounds made on the piano causes him real mental suiTenng,
wbereas when he was in health his musical taste and discrimination of
tike pitch and quality of sounds were below mediocrity.

Drowsiness is verj' generally present; at first, perhaps, to a slight
ext«nt, but sooner or later as a prominent feature. Headache is very
fommtiri, and is usually dull and circumscribed. The forehead is its
tnnrt wmmon seat. Other sensations in the head, such as vertigo, full*
R«% weight, and constriction, are scarcely ever absent.

Gradually, the condition of the patient, mentally and physically,
Wooracs weaker and weaker, and death ensues, immediately preceded
br coma, eonvidsions, delirium, or a combination of these phenomena.

Not unfrequently, softening of the brain is not preceded by h:em-
nrrltitij<*, thrombosis, embolism, or other evident affection, but begins
' ni\ advances very gradually. Such cases are often directly

i kso and obliteration of the cerebral capillaries, as described

ia iho immeiliately preceding chapter, or they may be the result of a
■low iallanimatory process. In this form the symptoms make their ap*
peMincc in succession ; but the paralysis, instead of being present from
wt boeptton, comes on very slowly, commencing as a slight weakness,
wjoioed with numbness, in one or more of the extremities, or in the
W Ordinarily, the first evidence of paresis is. discovered in the leg,
'Wrfi t d clear of the ground. The toe consequently strikes

igutMt i rial i ties of the pavement, and the patient is apt to fall,

es the weakness is shown by the leg suddenly giving way at
l&iw- I have had several patients with cerebral softening, in
iKis accident was of common occurrence, and who had thereby
mi Jicvpri^ injuries. Or, when the ann is the paretic member, the
tai shown by the dynamometer, is materially lessened in strengtli,
thingai held in the hand are dropped. I have now a patient in
iu whom the affection is in its very earliest stages, and of which
manir«'4iitioris are, clipping of the words in speech and paresis
^^ arm,

T^h ' >[ the muscles to maintain a continuous contraction for

^^Wt ugh met with in several other aiTeotions, isio some ex*

148

DISEASES OF T«E BRAIN,

tent characteristic of cerebral softening, and, in conjunction with ihe
other phenomena, Is a valuable indication. Even before it has become
so far developed as to attract the attention of the patient or those about
him, its existence niaj be ascertained by moans of the dynamograph
described in the preUininar}* chapter of this treatiae. It will often be
found that a straight line cannot be madej but that the pencil pursues
a jd^ag coui-se, or else one descending with more or less regularity.

The paralysis usually goes on to complete loss of power, though its
progress is often very slow, and is marked occasionally by periods of
decide<l improvement. At th^se times the patient's friends imagine
that he is about to recover, and if, as is sometimes the case, the mental
symptoms are likewise mitigated, their hopes are still further ex&lted.
It is necessary that the physician should not be deceived. In a case
which I saw in consultation with Dr. Chamberlain, of this city, I diag-
nosticated chronic softening. At the time, there were feebleness ot
memory, paresis of one side of the body, and difllculties of speech. I
gave an unfavorable prognosis, but soon afterwani amendment began,
and the patient, who was an insurance agent or appraiser, resumed his
business to some extent. I nevertheless adhered to my opinion, for I
had seen too many cases of similar character to be deceived in so dear
A one as this. I never saw the patient again, and am therefore unao-
quainted with the subsequent phenomena, except that about a year
afterward I was invited by Dr. Chamberlain to be present at the post-
mortem examination. His brain contained v^ foyer of softened tissue as
largo as a walnut, apparently the result of obliteration of the posterior
branch of the left middle cerebral artery, and involving a portion of the
middle lobe of the left hemisphere.

In another case, which I had very thorough opportunity for study-
ing, the patient, a gentleman thirty-five years of age, was the subject
of chronic softening, without any histor}^ of previous lesions. The di^
ease had come on very iiii^idiously, first showing itself by a slight im-l
pediment of speech and impairment of memoiry. Gradually he loetj
power in both anns and both legs, though the right side was more
affected than the left. His gait became titubating, and although he
never lost the ability to walk, yet he did so with great and increasing
difficulty. But hia stages of apparent improvement were at first nu-
merous and well marked. His memory at such times was stronger, \m
oountenanco brighter, his articulation distinct, his emotions more under
command, liis power of attention increased, his intelligence equal to all
ordinary occasions, and his walk free from any sign of debility. Then
all these steps would be suddenly lost, and he would again become
imbecile and weak. Finally, a sivere convulsion, more evident on the
right side than the left, supervened one evening after dinner, as he was
quietly smoking a cigar. Between seven 'and twelve o'clock that night
he had over a hundred fits. He died at the latter hour. Tlie post-

CEREBRAL SOFTEN^IXG.

iftortetn exatntoation reveuled the existence of a large centre af soft-
ening^^ involving the middle lobe of the left hemisphere*

Sometimes the course of the disease is still more irregukr. No
mdence of cerebral disorder is perceived beyond aphasia, and the
j»turnt remains in the full pogses«ion of his intellect, and without pa-
fily8i% up to a short time before death, Durand-Fardel * cites the case
of a mjiii, thirty years of age, who entered the H6tel Dieu, presenting
nil the ^igns of pulmonary phthisis. In a few days afterward he expe-
ilcnoed ditBculty of articulation, in thirty hours ho becs'ime comatose,
ittd, in twenty more, died. Tlie post-mortem examination revealed the
existence of softening of the inferior surface of the left middle lobe
c*( the cerebrum* Although it is not go stated — Diirand-Fardel hav-
ing written previous to Virchow's observations — ^there is little doubt
th&t the cause of the softening was an old embolus in the left middle
cerebniJ artery.

[^llemand,* in his first letter, cites several cases in which the dis-
«jie was marked by singular symptoms, such as convulsions, contrac-
imif and delirium.

la i case which I saw in consultation with Prof. C. A. Budd and
Dr. J* T, Taylor, occurring in a gentleman about thirty-five years of
ft^, there were coma and violent hcmi-convulsions, evidently due to
•utteairig from embolism, of which there had been two attacksj tho
litt s*ivt'ral weeks previously. Death ensued, but no post-moHem ex-
«ttuij*tion was, I believe, obtained.

A ^ntleman is now under my charge who has valvular disease on
tHe l^ft «de of the heart, the consequence of rheumatic endocarditis,
«id who, six months since, had an apoplectic attack conjoined with
ipliriMa and right hemiplegia. !!<? soon became able to speak pretty
^^^\i aod regained p»ower and sensibility to a great extent in the para-
Ij^ limbs. During the past two weeks, however, he has exhibited
' rns of mental derangement, as shown by the existence of hal-
ins and delusldna, and is gradually losing the power of motion
^^'i of sensation on the right side. His speech is as perfect as it ever
**^ ami there is yet no sign of dementia*

It ha5i Imppened that individuals have died who, on post-mortem
^"ttination, were found to have softening of the lirain, but who,
^^ng life, had exliibited no sjTuptoms of this or any other cerebral
^ttlcf. Rostan, who was the first to write systematically on the
^^■cMe, rulers to such cases, and Durand-Fardel is still more explicit.
^ btter aays :

** We meet with softening of the brain in persons who, up to the
^^'^ of flc«.th, had presented no appreciable derangement of the cere-

' ^I^U da nuuollUsemcnt c^rebmle/' Fftria, 1843.

0 i?t 9efl d^p<^ndatie6j^*^ Taris,

150 DISEASES OF THE BRAIN.

bral functions, and in whom softening has been developed without
having given any evidence whatever of its existence." In such in-
stances the white matter of the hemisphere can alone be involved.

One such case verified by post-morten examination has occurred
within my own experience. The patient, a soldier of the Second United
States Infantry, died at Fort Riley, in Kansas, of which post I was
medical officer, of chronic dysentery, the result of exposure. There
were no mental symptoms, no difficulty of speech, no paralysis; nothing,
in fact, indicating the existence of brain-disease. He died in full pos-
session of his intellectual faculties. The post-mortem examination re-
vealed the existence of ulceration of the small intestines, and, as the
cause of death was very evident, the brain was not examined. I re-
served it, however, for purposes of study, and, on making a section of
the right hemisphere an hour afterward, discovered an encysted centre
of softening, including more than two-thirds of the posterior lobe. The
right posterior cerebral artery was entirely obliterated by thrombosis.
The man had been at the fort several months, and had never made
complaint of any illness till he was attacked vs-ith dysentery six weeks
before.

The duration of cerebral softening is very variable. Rostan found
it to range from a few days to several years. Andral, from an analysLs
of one hundred and five cases, found that the period was from twelve
days to three years. The most rapid case occurring in my experience
terminated in death at the end of eighty hours. Some confusion on
this point has arisen from the fact that some authors regard embolism
and thrombosis as essentially identical with softening, a doctrine which
is clearly erroneous, as, in many cases of these affections, recovery or
death may take place without the stage of softening being reached.
In the case above referred to, post-mortem examination showed that
the condition known as yellow softening was just making its appear-
ance. As I have already stated, I cannot regard the alteration called
by some pathologists red softening any thing more than the congestion
due to the active collateral circulation.

The case of longest duration, of which I have any personal knowl-
edge, was that of an eminent scientific gentleman, who had suffered
from the symptoms of softening of the brain for nearly four years, when
he died. There was no post-mortem examination, but the history of
the case was that of thrombosis of the left middle cerebral artery, and
the course of the disease left no room for doubt as to its nature.

The symptoms of cerebral softening which I have specified are
those which are in general the result of the morbid processes existing in
the cortical substance of the hemispheres, or in the optic thalami, or
corpora striata. Generally, as Laborde * has shown, whenever the corti-

• 1 " Lc ramollissemont et la congestion du cervcau principalement coDBidMs chez le
?ieillard," Paris, 1866, p. 1, «?< ieq.

CEBEBRAL SOFTENING,

y^L

ace is the seat of softening there is at least one other centre
\ the central part of the brain, or especialJy tho corpus stria-
tum or optic thalamus. But the other portions of the encephalic mass
are liable to be similarly affeotedy and then the phenomena are of a dif-
ferent character.

Thus the pons Varolii may undergo softening from occlusion of the
basilar artery, or of one or more of its transverse branches, or from disease
of its capillaries, or from chronic inflammation of its substance, and if the
disease be limited to this ganglion there is no marked mental deteriora-
tion or other evidence of intellectual derangement. The s^Tnptoms are
in the main connected with sensibility, and the power of motion with ar-
ticulation, and with the respiratory, circulatory^ and stomachal functions,
aa eridenoed by dyspncca, irregular action of the heart, and nausea and
IPomitiftg. In the case of an elderly gentleman whom 1 saw in the early
part of 1874, and who had been affected for about a year, there was
mfaoofit complcfte paralysis of the lower part of the face on both sides,
lltefcs was great difBculty of swallowing, the tongue could not be pro-
truded, speech was very indistinct, the respiration and action of the
bcart were irregular, and the limbs were partially paralyzed. There was
m gvucrni loss of sensibility throughout the whole body, and attacks of
TtTiigo and epileptiform convulsions had been frequent. At the sami^
lime the intellect was as clear and exact in its operations as it ever had
been. I diagnosticated glosso-labio-laryngeal paralysis, and expressed
ibe opinion that the patient would not live over a month. Ho died in
two wiNiks. The [>o9t-mortem examination showe<l the hemispheres and
oerebetluni and the membranes to be healthy. The basilar artery was
Witirely closed by a thrombus. The pons Varolii was as soft as cream,
sncl tlir membranes peeled off as easily as if they had never been at-
taolic4 to it, Kxamitied microscopically after due preparation, the cap-
itbiries were found to be in a state of atheromatous degeneration. The
medaUa oblongata was not softened, but extreme atrophy of nerve-cells
bad taJcMt place in the nuclei of the facial ner\^e of both sides. This
point win be further considered under the head of atrophy of nerve-cells.

Softening of tlie cerebellum can scarcely, in the present state of our
knowledge, be diagnosticated from any other affection of that organ,
Thm rmpid form^ such as results from embolism of tho larger vessels, pre-
Mflls 00 many analogies with haemorrhage that there are no sure signs
bj wMeh a discritnination can be made; and the slow form due to disease
of the capillaries or to chronic inflammation is not distinguished from
I or tumor* But it may be inferred that the cerebellum is the
ol ttructural change when the category of symptoms cited ufider
tbe hrftd of cerebral haemorrhage is present, and the history of the case
viU oftivn aid ua in forming an opinion of its nature not very wide of
tb^ mmrk.

Wben deoth results from cerebral softening, it may be directly due

152 DISEASES OF THE BRAIN.

eitber to the tlLseaso itself, or to some intorcurrent affection. Tims the
patient may die from pure exhaustion or from slow asphyxia ea.U£eil by
the imperfect action of the respiratory function^ or he may choke to
death either by being unable to swaUow food which he has taken inta
his mouth, or by the regurgitation of the contents of the stomach during'
a convulsion, or a severe convulsive seizure may cause immediate aa-
phyxia, or a series of oonvulsioos may produce a more gradual asphyxia,
or he may die in a state of profound coma.

The intercurrent affections may be either meningitis or hypostatic
congestion of the lungs from long confinement to the recumbent p^^^j
ture, or diarrhoea, or a fresh attack of thrombosis or embolism. ^^^H

Causes. — The etiology of cerebral softening has already been csfl^^f
sidered to some extent under the heads of cerebral hn[>morrhage, ativ^H
obliteration of cerebral arteries and veins and of the capillaries, from
embolism and thrombosis, of which conditions it is so often a sequence;
but, as it may occur without having been preceded by either of these or i
other noticeable affections, a few additional observations are necessary.

Age is certainly a strong predisposing, if not an actual exciting i
cause, although the disease is observed at all periods of life. Rostan^ J
whose cases were collected at the Salp^tri^re, a hospital containing only
old women, found that there were ten cases in persons between the ages
of sixty and sixty-nine, twenty between seventy and seven ty-nine^ and j
ten between eighty and eighty-seven. Andral, excluding cases occur-
ring in infants, found that, of one hundred and fifty-three cases, there
were between the ages of

15 and 20.....,,.,.,...... 10

20 " 80.... , ..., IS

so " 40 11

40 ** 50. , , .._.!»

50 *♦ 60 j7

60 " 10 ai

70 " 60 .30

80 " S». , .. 4

Durand-Fardel, from an analysis of fifty-five cases, found between
the ages of

so iind 40 ,3

40 ** 80... , 8

50 »' 55... .....-,..,, t

60 " 70 14

70 " 80 53

80 *• 87 , r>

The period of life, therefore, at which softening is most apt to occur,
is from the age of fifty to eighty.

During the past ten years, forty-five cases of cerebral softeoiiig,

CEREBRAL SOFTENIXG, ^^^^^^^ 153

IIm result either of hapinorrhage, arterial embolisnij or of arterial or ve-
noos tlirombosLS, have been under my care or been seen by me in consulta-
tion. Of these, one was under twenty years of age; four were between
tvv 1 thirty years; nine between thirty and forty; twelve between

f<L'; ifty; eight between fifty and sUty; eight between sixty and

mrentfi and three between seventy and eighty. The general results,
iberefore^ go to show the greater proclivity which advanced age gives
14) the occurrence of the disease* In one of those between seventy and
eighty, the mind was scarcely impaired till about two moutlrs before
dsftthy though there had been paresis, headache, and aphasia, for two

Xo definite statistics have been collected relative to the influence of
•ex, although the opinion appears to prevail that the affection is more
liable to occor in females than in males. Of the forty-five cases just
cited^ twenty-nine were males and sLvteen females.

The season of the year does not appear to exercise much influence*
Dnrand-Fardel^ from sixty *three cases, found that seventeen occuiTed in

ter, thirteen in spring, twenty in summer, and thirteen in autumn, I

c found it difficult in many cases, from the insidious or hitent charac-

of the early s^mptoms^ to fix the period of beginning with accuracy.

Intense and long-continued intellectual exertion is one of the most
isoimmon causes of cerebral softening. Kleven of the cases occurring in
my experience were clearly the r^ult of this cause. Severe and pro-
limeied emotional disturbance was apparently the cause in four cases.

Roatan, among the causes, cites insolation, the action of intense cold^
blows upon the heatU and excessive use of alcoholic liquors.

The influence of obliteration of the cerebral arteries, sinuses, veins,
mni] capillaries, in producing partial cerebral anicmia, and hence as lead-
mg to the supervention of softening, has already been dwelt upon at suf-
feieiit length.

DiflLg^OSis.^ — ^Tho history of haemorrhage, thrombosis, or embolism,
when these conditions have either of them given rise to softening, will
aid in the diagno^^is. The signs which serve to distinguish these affexs*
tions from others have already been amply considered,

WTien there is no such previous clinical history, softening of the
biutJi 'may be confounded with chronic- meningitis, meningeal hannor-
rlui^ or tumors. From chronic meningitis it is to be distinguished in
nw^ cases by the facts that in the former the headache is generally
diffused, while in softening it is fixed, that the paralysis is more limited,
that there are frequent spasms of the Umbs, that there are well-marked
febrile exacerbations, and that there is not the progressive enfeeble-
ment of the intellect so characteristic of the vast majority of cases of
ccfL^brd softening. At the same time it must be admitted that the diag*
sometimes cannot be clearly made ont.

In roeniiij^l hiemorrhage coma occurs as an early symptom, gradu-

154 DISEASES OF THE BRAIN.

ally increasing in intensity, whereas in softening it comes on at a late
period. Hiematoma of the dura mater, however, may readily be oon-
founded with softening. The history of the case will aid in the forma-
tion of a correct diagnosis.

In tumors the most prominent symptoms are pain and convulsidnSy
while the intellect usually remains unaffected. The pain is exceedingly
intense, while in softening it is dull. The speech in tumors is generally
unaffected.

Prognosis. — Cerebral softening in general ends in death. Neverthe-
less, it is not altogether hopeless. If the patient be young, of good
constitution, and of temperate habits ; if the centre of softening be
small, and not involving the more important parts of the brain, there is
some encouragement to expect a favorable termination. Some of the
cases cited in this chapter go to show that recovery is possible, and I
have certainly seen others with the ordinary initial symptoms of oere-
bral softening recover with appropriate medication. Such patients,
however, were all under the ago of forty, and were of good constitution
and habits. In softening due to embolism, and occurring after rheuma-
tism and endocarditis, the liability to future attacks must not be oTer^
looked. I have seen as many as six attacks of embolism occurring in
the same patient, and yet no morbid condition beyond that of anflemia
set up, and again cases in which a single embolus has caused softening
and death.

Morbid Anatomy. — In the softening of the brain which results from
the obliteration of arteries or veins by embolism or thrombosis, the first
stage after that of congestion from the excessive action of the collateral
circulation is what is called yellow softening. This is not, as some
authors have supposed, produced by the infiltration of pus into the
cerebral substance, but is caused by regressive metamorphosis of the
brain-cells into fat, the granules of which are mixed with the coloring
matter of the blood which gives rise to the peculiar yellow color. The
white corpuscles of the blood also undergo degeneration into fat.

These altered white corpuscles were described by Gluge ' as inflam-
mation corpuscles, under the idea that softening was always the result
of inflammation. Labordo,' who has studied this subject with grea^
success, shows, however, very conclusively that the transformation is i^
true degeneration, a part of the fat-corpuscles being derived, as stateA
above, from the nervous fibres, the cylinders of which disappear, tho
contents being extra vasated, and with the myeline being converted inta
fat; and another part consisting of altered white blood-corpuscles. At
this time the cerebral tissue is pulpy, constituting a centre of softening
or 9k foyer ^ the consistence of which is greater at the circumference than
at the centre. The blood-vessels passing through the disorganized po^

» '* Atlas of Pathological Histolog}'." Translated by Leidjr. Philadelphia, 1853.
' Op.cU,

CEREBRAL SOFTENlNa ^^^ ^55

itoii are e&sUy separated from the perivascular tbsue and am covered
with oO-globales.

The seoottd stage is designated white softening, and in it the brain-
substance loses altogether its moq>holo^ical characteristics, and appears
as a white, crcam^liko matter so soft that a weak stream of water, al-
lowed to iinpingo upon it, washes it away. In this semi-liquid matter,
whitish t}akes of denser tissue arc suspended. Microscopical eiLamina-
lion shows that all traces of nervous structure have disappeared, and
tliat no anatomical elements remain except oil-globules and organic cor-
puscles somewhat resembling leucocytes.

When the morbid process involves the cortical substance of the
corebnini^ the convolutions undergo a peculiar kind of transformation
iirat pointed out by Cruveilhier, and then by Durand-Fardel ' as occur-
liog in the senile form of softening.

Tliia is characterized by the fonnation of yellow plates, irregular in
form, soft to the touch, but yet sufficiently dense to resist the action of
a thin stn^atti of water* Microscopically they are seen to consist of
ituelcated fibres, fat -corpuscles, fat-globules, and degenerated capillaries,
with blood-crystals and granular matter. Essentially, therefore, they are
formed of connective tissue.

'Ilio degenerated nerve-tissues, constituting a focus of softening,
mmy undergo absorption. In such a case, a cicatrix, similar in general
ehiikraetensttcs to that resulting from the curative process of hcemorrhage,
fcf&alns.

Ill the Hoftoning resulting from inflammation, a somewhat different
•ei of morbid appearances exists. Thrombosis and embolism produce a
true death of the parts previously supplied by the occluded vessels, a ne-
Cfobioaift, ts it has been called by Virchow. The process is accompanied,
as we bare seen, by degeneration of the nervous tissue, but in the sc»ft-
nittng due to inflammation new formations result. Sometimes the two
coexist, but the latter is occasionally an entirely independent action.

When such is the case, connective tissue is generated, and the ner-
V01I8 «al>5tance is rapidly broken down. An exudation of an albumi-
ooas 6uid containing fine granules, the disintegrating nervous substance
aoil numerous flakes of coagulated fibriae, takes place, and with blood-
oorpuscles causes the centre of softening to present the appearance of a
reddish pultaceous mass, easily washed away by the action of a weak
tftr^am of waten With age the color of this softened tissue becomes
or yellow. Sometimes, when the inflammation has extended to
't parts of the cerebrum, the contents of the cyst are pene-
tf9ted by the new coanective tissue. The pulpy mass undergoes partial
absorption, and is replaced by a white turbid liquid, called by Cruveil-
hii?r and Dechambre "milk of lime" (lait de cbaux). Durand-Fardel
dmpiatcs this form of softening '^ cellular infiltration,"
• '* Maladies dca vieilLirds," Paris, 1854, p» 71

156 DISEASES OF THE BRAIN.

The softening resulting from occlusion of the capillaries, a condition
not recognizable during life, does not differ essentially, except in its
situation, from that which follows embolism or thrombosis of the larger
vessels. The centres of the process are, however, smaller, are generally
numerous, and usually met with either in the cortical or white sub-
stance, or in the corpora striata. The morbid anatomy of the affected
vessels has been sufficiently considered in the previous chapter.

^^Tieu disease of the capillaries has been the cause of the softening,
these may be ruptured, and we meet with minute extravasations of
blood in the disintegrated perivascular tissue, constituting the " capillary
ha?morrhage " of Cruveilhier.

Pathology. — ^The first definite accounts of cerebral softening were
given by I-»allemand * and Rostan,* both of whom published their works
in the same year, 1820.

In the very beginning of his first letter, Lallemand awards to MM.
R6camier,Bayle, and Cayot, the credit of describing the condition under
consideration, and of giving it the designation by which it % so general-
ly known, even out of France, of ramollissement. Lallemand then pro-
ceeds to define the term by saying that, by ramollissement of the brain,
ho understands a kind of liquefaction of a part of its substance, the re-
mainder preserving its ordinary consistence. He then quotes cases
from Morgagni and Abercronibie, and cites others from his own experi-
ence; and then concludes by declaring that he does not hesitate to
range cerebral softening among the inflammations, in which opinion he
is supported by Abercrombie.* Rostan * regarded the disease as some-
times being due to inflammation, and sometimes to degeneration of the
blood-vessels. Bouillaud * viewed it as an anatomical feature of inflam-
mation. Cruveilhier • considered what he called red softening as result-
ing from the capillary haemorrhage previously mentioned, and that other
forms were certainly due to inflammation.

Andral ' recognized the fact that softening might result from inflam-
mation or capillary haemorrhage, but he also insisted tliat it might be
due to special alterations of nutrition, caused by different morbid influ-
ences, such as- obliteration of the arteries supplying the brain, or im-
poverishment of the blood.

MM. de la Berge and Monneret • adopted in part the views of Ros-
tan relative to degeneration of the cerebral vessels as a cause of soften-

• *' Rechcrches anutomico-pathologiqucs sur I'encdphale," Paris, 1820.

' "Rechcrches sur le ramollissement du cerveau," Paris, 1820. My references to
Rostan's work are to the second edition, of 1823.

■ Op, cU.y p. 205. * Op. ctV., chapter viL

» "Trait6 de Penc^phalite," Paris, 1825.

• Art. "Apoplcxie," in " Dictionnaire de mddocine et de chinirgie pratiques."
' " Clinique m6dicale."

• '* Compendium de m^decine pratique."

CEREBRAL SOFTENING.

15T

'Curswt'ii' regarded softening' occurring during life as being af-
fected liy these circumstanoes^ — inflammation, obliteration of arteries,
[ «i|lld modi fi cation of nutrition.

Fuchs^ appears to think that inBammation is not a necessary ante-
cedent, but that congestion is. He also admits obstruction of the
arteries at the base of the brain to be a cause.

The studies of Durand-Fardel * have been very thorough, and hare
ooDtributed greatly to our knowledge of cerebral softening. According
to him, the affection is an inflammation vrhich does not differ essentially
from other inflammations occurring in the young or old. White soften-
iug he rvgards as the chronic form of the disease.

Other pathologists publisJied the results of their observations and
generally to the same effect as those which have been quoted, viz., that
e^rebra.! softening was an inflammatory process, and sometimes one re-
iultitig from obliteration or disease of the arteries, A few, however,
faeki to the riew of Lallemand and Durand-Fardel, that inflammation
was alw*ays tke start ing*point.

Iti 1847 Virehow published his observations relative to emboUsm, and

the partial cerebral anaemia produced by occlusion of an artery thus be-

fxaiQ s recogniied fact. In reality, it came to be regarded as the only

ctmmm capable of giving rise to softening, and many pathologists of the

pfwieiit day entertain such an opinion. But I think this is carrying the

tfaieoiy further than facts will warrant. I cannot altogether disregard

>tbit fesearches of Durand-Fardel,* Calmeil,* Rokitansky,' Wedl,^ and

^ and although I cannot agree that all cerebral softening is a con-

of inflanunation, 1 ara very sure it has this and other c^auses

thrombosis and embolism. Calmeil^s work is a monument of

cafofol observations and scientific deductions, and his fifth chapter (tome

ii.), entitled ** Du rnmolliitsinHrU ctribral local ai(/itj on ih rcnchplia-

iite lacaU ait/ui sans cat Hots sattf/uhts si^t/eant sous la forme (Tun foyer

^>'i ihjt piusknrs foyers circQnscrUs^ soU h la surface^ aoit dans la pro-

nr ik la masse cnciphaliqye^'^ containa cases which are amply

auUicHiit to establish the point for which ho contends. He shows, too,

in other chapters of his treatise, that softening results about the periph-

>fPi]r of dots due to cerebral hiemorrhage.

Tho weak feature of Calmeil's otherwise very complete work is, that
hit iilogptiier ignores Virehow, and those after him, who have oonfirmed
^ facta and theories*

* Art. « Softenhig of Drgims,*' in ** CvctopiedtA of Pnictioal Medkriao,'* vol. iv., p, 176,
^ouiHima (MntioB.

* ** BcoImi' I ml Ilomerkungien ubcT Gehirnorwdohung " Ldpdg, 1 888,

* •• Tt^lk -fMnrtit Uu ccrrcttu/' PuK?, 1 84 S»
**'mMk^a< ^ Paris, 1854.

* '*T»ll4 d^ tt. inimatoirt!* tlu cerrenu,** Paris, 1850.

* * Ftthologlcal Auui«iinv/' %deQham Society traasliition, 1850.

* **Biidlm«aU of Pathokigical Ubtology/' Sydealiam Somty trih&flbttiaiiy ISlHi.

158 DISEASES OF THE BRAIN.

Soulier/ on the other hand, can see in softening nothing of the
nature of inflammation. For him it is always a necrobiosis, produced
by the cessation of the physiological action of the blood, obliteration by
embolus or thrombus, by diminution of the calibre of the vessels, or oc-
clusion resulting from atheroma or obstruction of a vein or sinus. He
admits that the obliteration of an artery may cause congestion behind
the point of obstruction, by which the coagulation and capillary hseraor-
rhage of acute softening — ^the capillary apoplexy of Cruveilhier — are to
be explained. This red ramoUissement has, however, nothing of the
nature of inflammation about it.

The only points in which I differ with Soulier are, that I cannot
regard softening as being solely due to occlusion of blood-vessels, and
that I am very sure the congestion which follows thrombosis or embo-
lism is not necessarily the first stage of softening. There is no more
reason why partial cerebral anaemia should always result in softening,
than that ligation of the femoral artery should always lead to gangrene
of the parts below.

Obstruction of veins and sinuses in the brain may be followed by
softening. The clot is usually the result of injuries or disease of the
cranial bones or cerebral membranes, especially the dura mater. It may
also be caused by certain cachectic conditions in which the blood is
deteriorated in quality, such as typhus and typhoid fevers and
cholera.

Four cases, in which this latter affection was followed by thrombo-
sis of the superior longitudinal sinuses, with consecutive softening, have
come under my observation. In two of them there were also thrombi
in both femoral veins. The upper surfaces of both hemispheres were
the scats of the softening, which involved the gray matter only.

Thrombosis of the veins or sinuses may also in general terms be
produced by whatever cause is capable of retarding the current of
blood. Mr. Toynbee,' in his chapter on diseases of the mastoid cells,
has brought forward several cases in which the lateral sinus was occluded
by coagula, and in which there was cerebral softening.

Cerebral softening may also result from the formation of adven-
titious growths, or from the presence of foreign bodies in the brain*
In such cases the process begins with inflammation, and is similar to
the action which sometimes goes on around an extravasation of blood.

Acute cerebritis or meningitis may likewise result in softening.
This fact is admitted by Drs. Russell Reynolds and Bastian, in their
admirable essays on cerebritis and softening of the brain, though with
evident reluctance.

We see, therefore, that cerebral softening may be caused either by
annemia or inflammation, and that it is of two kinds, inflammatory and

' Journal de mSdeeine de Lyorty F6vrier, 1867.

^ **Tbc Diseases of the Ear, their Nature, Diagnosis, and Treatment,** London, 1860.

CEREBRAL SOFTENING,

159

•inflammatoiy. The seat of the softening may be in any part of tho
bmin, although some regions are more liable than others. AVhen due
to thrombosis, there appears to be no predilection for any particular
location, but, as embolism is generally found on the left side in the
middle cerebml artery, the parts of the brain supplied by this vessel
mre more liable than the corresponding parts of the right side.

Dnrand- Fardel, however, did not arrive at this conclusion. Of one
hundred and sixty-nine oases of softening, he found the left hemisphere
tho seat in sixty-nine, the right in seventy-one, both in twenty-six, and
the middle line in three.

The gray matter is generally supposed to be more frequently the
seal of softening than the white. It is true that, of thirty- three casea
of acute softening observed by Durand-Fardel,* the convolutions were
uiYolved 10 thirty -one, but in nine only were they the sole part af-

Ia fifty -three cases which the same author colleotod from the writ-

Hostan, Lallemand, and others, the centres of softening were

Ho be as stated in tho following table. Occasionally more than
doe region was involved,

Coarolutiuna tnd whit« fiubetancc iS

OottTottttianB alone, ,.....,,. a

WkiiCe tubtUnce alone ♦ •,...... , • t^

Cotpus strtiilutn and optic th&lmmue , » a

norpQ9 •triatum alone, .,.,.. , , , . v • 11

r« ifuusalone , *••«•»• 4

I i 8

Crux ctjTt^hri. , , ,»••,.,,.•.. I

C<>rfiu# oallofium , , 1

Wftlb of ih« ventricles (*cptum). , . ., 1

9atnit ._... i

Oervbdlutii ..... 1

Ikiistanf on the other hand, found the corpora striata and tho optic
to be the pftrts most frequently affected, and after these the
! part of tho hoin'mnlionvs. H<* met with but few cases involving
till* median liii'

lii'j Ireqiicncy with which the convolutions with the
irii ^^ were involved, as compared with the motor tract, he

found tbat^ of one hundred and seventy-seven oases of acute and
dkfoiiin softening, the convolutions and whit© substance were affected
in on« hundred and luneteen, and the corpora striata and optic thalarai
In fifty-eight.

Th« middle lobe is more liable than any other, as is seen in the fol-
lowing statement of Du rand-Fardel, based upon an analysis of ninety-

' ^ Triii6 da rainotliasemetit da oerveau,'* Paris, ISiS.

160 DISEASES OF THE BRAIN.

Posterior lobe 18

Middle 51

Anterior 18

Posterior and middle 7

Posterior and anterior 2

Middle and anterior 2

Whole convexity of hemisphere 1

Middle line. 1

In more than one-half of the eases, therefore, the middle lobe was
the seat of the disease.

A question connected with the pathology of cerebral softening, as
with haemorrhage, is, " Can w^e detennine, from a consideration of the
symptoms, what part of the brain is the seat of the lesion ? ** The
answer must be the same. We can do so with some approach to ac-
curacy, but, till we are better acquainted with the physiology of the
different ganglia composing the brain, we cannot expect to do so with
absolute certainty. Indeed, owing to the greater extent of tissue in-
volved, compared to that affected in haemorrhage, we have a more com-
plicated set of phenomena to deal with. I have nothing further to
add to the remarks made on a similar point, under the head of cerebral
haemorrhage.

Treatment. — The treatment proper for cerebral softening should de-
pend very much upon the cause from which it has arisen, and must
more or less be directed against the symptoms which are manifested.
Thus, if there is reason to suspect the existence of thrombosis or embo-
lism, and a consequent anaemic condition of a portion of the brain, the
judicious use of stimulants and tonics is advisable, while the body should
be kept warm by additional clothing, or the application of artificial
heat — at the same time the recumbent posture should be assumed, and
the head supported on a low pillow. Mental exertion should, of course,
be absolutely interdicted. If there be much headache, it is probably
due to too great an activity of the collateral circulation, and in such a
case some one of the bromides may be given in large doses, repeated as
often as may be necessary. I have frequently seen great relief follow
their administration.

Delirium is often due to a like cause and may be similarly treated.
Dr. Reynolds * speaks highly of the Indian hemp in doses of a quarter
to half a grain of the extract; but I have found the bromide of potas-
sium, in doses of thirty grains every three or four hours, more effica-
cious. It is also the most beneficial remedy in the convulsions which
frequently precede a fatal termination.

In that fonn of softening which is obscure in its origin and gradual
in its progress, there is a little more hope of a favorable result, though
even here it must be confessed that treatment is not often effectual.

1 Article, " Softening of the Brain,*' in " System of Medicine," toL IL

CEREBUAL SOfTENING.

ICl

tave said, when speaking of the prognosis, there are un-
doubtedly eases in which recovery has taken place, and I am very sure
tbst I have several times succeeded in curing individuals who, so far as
I hav6 boea able to judge, were affected with cerebral softening. As
tbese cases are interesting in themselves, and as the histories will show
Ihe lEuians of treatment employed, I do not hesitate to transcribe the fot
loiring typical ones from my case-book:

L — ^ilr, R., a gentleman, twenty-four years of age, awoke one .morn-
big about the middle of March, 1870, with a sensation of numbness ex-
tamling tJirough the whole of the left arm and leg, and with a feeling
nC Tertigo which was insupportable when he arose from the bed. He
siU down in a chair, and while in this position was conscious of a buzz-
ing sound in the right ear. In the course of half an hour the vertigo
passed off, but the numbness and sound in the ear remained^ and he oc-
caik>aally saw double. In a few days afterward he noticed a slight
difficulty of articulation, owing to apparent thickness of the tongue, and
about the same time observed that in the morning the pillow was wet
witli the saliva which had run from his mouth during sleep. His uncle,
% wealthy gentleman of this city, sent him off traveling^ but he returned
!q a few wiseks with loss of power in the left arm and leg, which had be-
giui to b« manifested to a slight extent before his departure. He came
ttDifer my charge May 15, 1870.

Al this time the paralysis, of both motion and sensation, was well

marked on the loft side, as shown by the test hesio meter and dynamom-

•Ut, The line made by the dyuamograph with the right hand was

perfectly straight, while that made by the left was at an angle of forty-

ife degrees with the other. In his conversation he cb'pped his words,

aiii* (lies left out the smaller ones. His memory he stated was

fill itnpaired. There was almost constant headache over the

whole frootal region, and attacks of vertigo were frequent. Tliere was

ao marked paralysis of the face^ though the muscles of both sides were

par&tiC| and he often had double vision. The right pupil was largely

dil«t.?(l and was insensible to light.

(^hthalmoscopic examination showed the left eye to be perfectly
but the retinal vessels of the right were smaller and straight,
tbfs choroid was paler than natural.

Upon inquiry I ascertained that he had given extraordinary atten-
*^*oa to Ids business for a period of several months before the attack of
tttunLiicJW, frequently being up making calculations till three o'clock in
tilts morning, and thus depriving himself of the necessary amount of

Uv opiuioQ was, that he was suffering from incipient softening of
^ brain due to disease of the capillaries, which, in its turn, resulted
! sj ion and exhaustion. I was further of the opinion
V Ivod the right hemisphere and motor tract.
11

DISEASES OF THE BRAIK.

I prescribed the phosphide of zinc in the dose of the tenth of m^
grain, with half a grain of extract of nux-vamica in pill tliree times m,
day, with the constant galvanic current three times a week, the latte
to be derived from fifteen of Smee's cells, and to be passed from fore^
head to occiput for three or four minutes at a time* At the end of ten
days he had lost his diplopia, the pupil of the right eye had regained
its natural diameter and irritability, and the vertigo and headache haJ
notably diminished. The treatment was continued, and at the end oi^
a month he had recovered the sensibility and power on the paralyse
side to such an extent, and had improved so much in other respect
that I advised him to take a short journey. He was absent two weel
during which period he continued to take the pills as before^ and
his return was, to all appearance, well. He has since remained ia ex-^j
oellont health,

n. — Mr. R. W., a merchant of this city, consulted rae in Apnl, 18^8, 1
under the following circumstances:

' After a long period of great domestic anxiety, during which he inkd
been engaged in some heavy commercial transactions, and had suffered
from wakefuLaess, he experienced one afternoon, while riding in the
park in his carriage, a slight quivering motion at the apex of the tongue.
It continued until he reached home; and then, upon looking in a ™^'^|
ror, he could see the fibrillary movement very distinctly. He was notl
alarmed, and went to bed at his usual hour. In the morning he noticed j
a little thickness of speech, but the movement had ceased. That after-i
noon he had a violent headache, attended witJi vertigo and nausea. Be-
coming alarmed, he sent for his family physician, who ascribed the
symptoms to indigestion, and administered a mild cathartic. The foU j
lowing day, on attempting to rise from the bed to go to the water* 1
closet, he was attacked with such a severe vertigo that he was obligodj
to lie down again; and, though he did not for a moment lose conscious*]
ness, his freces escaped from him involuntarily. From tltis time h«|
gradually lost strength in both arras and legs, and Lis speech becamal
very defective. His memory suffered to such an extent that he foi^goii
the names of his children. There was very Httle headache, the vertigo J
had ceased, there was no disturbance of vision^ and no loss of po^
over the spliincters. About six weeks after the occurrence of the firefel
symptom noticed, he came under my care.

At this time there was anix^sthesia of both sides of the body, botlll
legs and both arms had lost power j he clipped his words, and froqueatll
substituted others of similar sound or meaning for those he ou^tl
have used. His memory was much weakened, and there was a etrooi^l
tendency to stupor. There were no troubles of the special senses
ophthalmoscopic examination revealed nothing abnormal^ — there was no
facial paralysis. I diagnosticated softening of the brain from general
cerebral ana?mia consequent upon congestion and cerebral exhauatlou

CEREBRAL SOFTENING,

163

and I prescribed a liberal allowance of wine, a full and nutritious diet,
carriage exercise, and amusements of various kinds* This was the very
revefse of the treatment to which he had been subjected. In addition,
I recomni ended the constant galvanic current, to be applied as in the
previous case, and gave the following prescription: IJ, Olei phosphomt.
fas; mucil. acacife, 3 j; oL bcrgamii, prtt. xv, M* ft. eraulsio. Dose,
gtt. XV. tcr die.

The treatment was carried out with the result of obtaining a gradual
and permanent imprdvement, so that at the end of about six months
ihe patient was well. He then went to Europe, where he now is, with
MB good health as he has ever enjoyed.

Other cases, similar in their general features, have been under my
care with a like result in each, and several others have been very decid-
edlj improved and relieved of the more prominent symptoms of the
dttMse, without, however, regaining full health. The means of treat-
ment thus far consist in the use of tonics, stimulants, and especially
|ibo^>horus and strychnine, the avoidance of all severe mental exertion,
am! all excessive emotion, open-air exercise, and the use of the constant
gmlvanic current.

The beneficial effects of maintaining the physical strength were
aereral years since pointed out by Mr. F, Skey * in a clinical lect-
ore delivered at St. Bartholomew's Hospital, but it must be con-
leBBed that the opposite plan of treatment has been very generally
foDowed*

Softening from the offects of thrombosis or embolism is, as I have
said, not ranch under the control of the physician. Patients recover
from it, however, when they are of good constitution, and when the
foctui of softening has not been extensi\ie. The mind and body may,
And in such cases generally do, remain feeble, and we are therefore
consulted for the relief of the condition* In such cases tonics, and
mmong them phosphorus, strychnine, and wine, occupy a prominent
ptaoi^^ the constant galvanic current to the head, and the induced to
tbe psndyied muscles, will rarely fail to be of service.

III. — ^Thus a gentleman, who had been a distinguished oflicer of the
ftnny, suflered from loss of memory, defective articulation, ptosis, double
▼iflioa, and right hemiplegia, probably the result of embolism. Several
years before he came under my charge, he had been treated by Dr. J,
T* Metcalfe, for heart-disease, the result of acute rhnumatism, I gave
tho phofiphide of zinc and extract of nux-vomica according to the for-
mula previously mentioned, advised a liberal nse of wine and beef- *
ileAks, applied the primary current to the brain, and the induced cur-
rwit to his jiaralyzed arm and leg, and in a few weeks had the satisfac-
tion af seeing such a degree of improvement as almost to constitute a

'^Od llie Valae of Toaic Treatment in some DiBeftses of tbe Brim, more eapeciall;
Cbi»f oC llamoSUtseiaeaif** DMtn HoapitQl Gatutie^ Norenber, 1858.

DISEASES OF THE BRll

cure. Tlie ocular troul^les LaJ (Usappeareil, bis aiemory had improved,
ho talked as well as over^ and the numbness and loss of strength were
no longer remarked unless he over-exerted himself, which, owing to hi
general feelings of bien ai^e^ he was very apt to do* Ue remained in
this condition for over a year, when he had several other attacks of
einholisnij each of which left hira more weak, mentally and physically,!
than before, and of which he eventually died.

There were some interesting features connected with this ease,
which will be referred to at greater length tinder the head of
aphasia.

IV. — In another case, in which there was reason to think a/byi
of softening had been absorbed, a marked relief from the sequelfls
obtained. The patient, a literary gentleman of distinction, had, several^
years previously to my seeing him, suffered from an attack of acute
rheumatism with endocarditis. About a month after Lis recovery, aa
he was sitting in his library before the fire, he felt a sensation as if one
side of his face had suddenly become much heavier than the other* Al*
most immetliately afterward he lost consciousness, and fell to the floor.
He could not have been in this condition longer than five minutes
when he came to himself, to find that he was paralysed in the right
arm and leg* Attempting to call for assistance, he found ho could
not articulate. His wife soon afterward entered the room, and medical
aid was obtained- He was bled to the extent of sixteen ounces, and
purged with croton-oil.

The following day he was much better; could move liis ann and
leg, and articulate with some degree of distinctness, but toward even-
ing headache ensued, he became delirious, and the paralysis increased.
Of the condition immediately following, lie could give no very cleat
account. He only knew that he was confined to Ids bed for seTeral
weeks, was delirious part of the time, and that, after the acute atta
passed oiT, he was left with an enfeebled mind, imperfect artimilatio
and paralysis of the arm and leg on the right side. He wont t
Europe, traveled extensively, and returned at the end of a year \c:
much improved, but still with some degree of mental weaknes:
defective speech, and paralysis, remaining.

"Wlien he came under my observation, the following were the prii
cipal symptoms observed; The strength of the right arm, as measure
with the dynamometer, was not one-third that of the left; the extei
sors of the leg and foot were almost entirely paralyzed, so that L
walking lie abducted the leg so as to cause the foot to clear tl
ground ; electro-muscular contractility was much weakened, thouj
the induced current caused feeble contractions. His speech was &.
fected mainly as regarded the memory of words. He spoke with i
good deal of volubility, but constantly used the wrong expressions
Thus, when he wLshed to tell me that he had visited Europe for lb

CEREBRAL SOFTENING.

pnefit of his health, he said : "I went to Elope for the bequest of my
hedge,'* and thea went on — continually raaking other mistakes — to tell
me a long* story which I could scarcely understand. His emotions
were easily disturbed: ho cried because he had to wait a few minutes
in my reception -room before seeing me,

OphthaJmoseopic examination showed pale choroids and straight
and attenuated retinal vessels. Auscultation revealed the existence
of both mitral and aortic regurgitation.

Taking into consideration the history of the case and the present
eoiidttion of the patient, I diagnosticated embolism of the left middle
eerebiral artery, subsequent softening and eventual absorption of the
dlMaaed part of the brain. My idea was that the brain, as a whole,
vii iiuemic, and that, with improved nutrition of it and the paralyzed
limbs, amelioration of the symptoms was possible.

I therefore prescribed the phosphide of zinc and nux- vomica pills
u bcforo mentioned, directed the use of wine to the extent of half a
liW of champagne daily, and advised that animal food should form
pnnct[)al portion of each meaU Since his illness he had, by direc-
tloa of his physician, left off the use of coffee. I directed it to be
wwmed^ and to be taken strong. The primary galvanic current was
pissed through the head in the manner previoujily indicated in this
?bpt^r, and the induced current was applied for half an hour three
linu'i a week to the arm and leg, each paralyzed muscle receiving a
Ml »hsre of attention.

It was not long before signs of amendment were noticed. His
ttwogtli liccame greater in the arm, and he was able to extend the leg
iftd to mise Uie foot after half a dozen electrical applications. Hia
■pwch next guve evidence of improvement, and his mind became
ititXQpsr. The treatment was continued for about four months, with
only tn intermission of a week. At the end of that time his gait was
ibim natural, though he still swung the foot a very little, his arm
^w nrjirly as strong as the other, his mind was not perceptibly weaker
t^Mi that of other persons of his age (fifty-five), and his speech was
UodUeiit except when he was excited and very auxinuj; t<> express
UiQjf if correctly and fluently,

llicre is one point in regard to which a few words are perhaps

**oeasar\, and that is to enter a protest against the use of counter-

^'Titiiiijo of any kind, and to discountenance, as far as 1 can, the em-

»iiTiT'Tt>nl of the actual cautery. 1 have never seen the least advantagB

tho application of croton-oil to the shaven scalp, nor can I con-

V Mich a measure can be recommended on rational grounds.

-iLV'-iral times witnessed its action, and have invariably seen it

■QTivite the symptoms. In the case of a gentleman from St, Louis,

•flictM with cerebral softening, the effect was to make his speech

■SI mare impetfect and his mind weaker, A lady, who was affected

lt]0

DISEASES OF THE BRAIN.

with all the more prominent symptoms of softening of the brain, '
ttll the phenomena increased in violence after the application of tho J
actual cautery to the nape of the neck* I could easily adduce other |
examples to the same effect, were it necessary.

CHAPTER YIL

APBASI A.

The subject of aphasia is of such interest, and so much attention
has recently been given to it by physiologbts and pathologists, that,
although it is only a symptom common to several morbid conditional
a treatise on diseases of the nervous system would scarcely be re
garded as complete without its being fully considered.

By aphasia is understood a condition produced by an affection of^
the brain by which the idea of language, or of its expression^ is ini
paired. The word is derived from the Greek^ — a, privative, and ^mo
speech — and, as stated by Trousseau, was proposed by M, Chrysaphis^
a distinguished Greek scholar, as a substitute for alalkiy used by Lor^
dat, and aphemia^ employed by Broca, to designate the same C5ondition.

In the definition which I have given of aphasia^ the term ib limit*
to impainncnt of the idea of language or of its expression. It
ootj therefore, include those cases in which the individuals are able
speak, but will not ; such as are met with among the insane- The idea
of language is as perfect as ever, and is doubtless entertaine<l, but th«
person docs not speak because he does not will to do so, and this fail-
ure may arise either from a lack of tho necessary power, or from a
stubborn determination not to speak. A lady was a short time stnco
under my charge who had been treated by a homceopathic pbysician
as a case of aphasia. A very alight examination was suiBcient to con-
vince me that the case was one of hysteria. She had not siioken for
several months, but upon one occasion she came to my office with hor
maid, whom she required to repeat the alphabet, and when the right
letter was reached she signified the fact by raising hor hand. She thus
spelled out the words she wished to use. Subsequently she proc\tred a
card with all the letters on it, such as are used for children learning
their alphabet, and she composed her words from this. Of course all
these facts showed that her idea of language was intact, but slie at
might have lost the power of coordinating the muscles concerned
articulation so as to express herself in spoken words. Althougli I was
sure this was not tlie case, I failed to make her speak, until one mom*
ing she became very much interested in something I was sayings and,
imding her alphabet too slow a means of expression, dropped it and

aaV

APHASIA.

167

eat fluency. After talking with energy fur a
quarter of an hciuFj she suddiMily reeullecteil herself ami took up her
ctrd of letters again, but the charra was broken, and by degrees she
resumed her speech. At one time this lady was under the care of ray
friend Prof. Flint , for some chest or throat diflficulty, and on one occa-
[»G spoke very well.
Neither does aphasia embrace cases of inability to speak from paral-
ysis of the tongue or other muscles of articulation* Defective speech
from this cause is frequently met with in hemiplegia, in glosso-labio-
lanmgcal paralysis, and some other affections. In such instances the
idea of language remains, but the patient does not speak because he is
onable to put the organs of articulation in motion. A few days ago a
Qtleman, a prominent merchant of the city, was sent to m© as a case
nf aphasia. As he entered my consulting*rooni, I saw^ that ho was
hemiplegic on the left side, and, on telling him to put out his tongue,
fotiad that he could not get it beyond the teeth, or touch the roof of
hi ' vrith it. The history of the case was that of ordinary cere-

If rrhage, and he regamed the power of speaking after several

tppiicmttons of the primary and induced galvanic currents had been made
10 the tongue and muscles of the face.

The distinction between aphonia and aphasia must also be made. In
th«> one the idea of speech is undisturbed, and articulation is not inter*
(ewd with except as regards phonation. Aphonic patients can whisper,
boi arrt unable to speak in full voice, owing to some laryngeal affection
og the tone of the vocal chords.
The ^t that the faculty of speech may be deranged independently
ffilher of the will, paralysis, or loss of voice, appeam to have been
ottcffid at a very early period in the progress of science. Thus Isaiah '
aya, ** For with stammering lips and another tongue will he speak to
thia people;" and again,' "Thou shalt not see a fierce people, a people
of A deeper speech than thou canst perceive j of a stammering tongue
that thou canst not understand,"

Tl] ' - mentions that many, who sufTered from the plague which

r»^l 18, found on recovering that they had not only forgotten

tl»e namea of their friends and relations, but also their own names,

Pliny,* in the chapter entitled Memoriw Mtempia^ says, in speak-
'''g of this faculty : **For nothing is so weak in man; disease, falls,
''•/ttries, even a fright, may impair it partially, or destroy it altogether.
A blow from a stone has abolished the memory of the alphabet. * A fall
''^'Cii a high roof has caused a man to ce&s# to recognize hb mother and
'*^i^libora, another even forgot his slaves, and Messala Corvinus, the
^^'•^Of, could not recall his own narno/' *

* Chiptir xxriil, 11, • Chapter wcxUL, 19, * Lib. rU., cap. xxiv.

^ ^^Miiwtt hii traniilAi^vl thU passage tomc^w hat dtlTorrtiUy.' I quote from an ilia*
I Mfiy printsil al Tarrtiium (TreYifto), In October, 1479.

168

DISEASES OF THE BRAIN.

Suetonius * relates that Claudius so far lost his memory that he
got the names of persons to whom he desired to speak, and could not
even recollect the words ho wished to use.

Passing over several authors of later times who have recognized thi
existence of the difficulty in question^ we come to Grichton,* who
marks as follows: "There is a very singular defect in memory^ of whiclij
I have myself seen two remarkable instances. It ought rather to
considered as a defect of that principle by which ideas and their proper
expressions are associated, than of memory, for it consists in this^ that
the person, although lie has a distinct nation of what he means to say,
cannot produce the words which ought to characterize his thoughts,
The first case of this kind which occurred to me in practice was that o
an attorney much respected for his integrity and talents, but who bad
many sad failings to which our physical nature too often subjects us.
Although nearly in his seventieth year, and married to an amiable lady
much younger than himself, he kept a mistress, whom he was in the
habit of visiting every evening. The arms of Venus are not wielded m
with uopunity at the ago of seventy. He was suddenly seized withv^
great prostration of strength, giddiness, forgetfulness, insensibility to all
concerns of life, and every symptom of approaching fatuity. His for-
getfidness was of the kintl alluded to. W^hen he wished to ajsk for any]
thing, he constantly made use of soiik? inappropriate term. Instead
asking for a piece of breail, he would probably ask for his boots ; but
if these were brought, he knew they did not correspond with the id<
he had of the thing he wished to have, and was therefore angry, Tel
he would still dcTiiand some of his boots and shoes^ meaning bj'ead.
he wanted a tumbler to drink out of, it was a thousand to one he did
not call for a certain chamber-utensil, and, if it was the said utensil he
wanted, he would call it a tumbler or a dish. Ho evidently was con-
scious that he pronounced wrong words, for, when the proper expres-
sions were spoken by another person, and he was asked if it were not^
such a thing he wanted, ho always seemed aware of his mistake, and oo]
rected himself by adopting the appropriate expression* This gentlemaa
was cured of the complaint by large doses of valerian and other proper
medicines."

Dr. Crichton subsequently mot with another case similar to the fore-
going, and he quotes the following from Prof. Gnmer, of Jena, in vol.
vii. of the Psychological Magazim, The patient, a learned gentleman,
after his recovery from an acute fever, suffered a loss of memory for
words. Among the first things he desired to have was coffee {^ffee)^
but, instead of pronouncing the letter^, he substituted in ita place a «,

^ **C Stiftonii TranquilU^*' xiK Cnpf^area,

' "Aa Inquiry into the Nature tind Origin of Mcnti! Derangement, comprehending %
CoEcUe SyBtem of the Phj^iolog)* an*! Fittholog^' of the Humau Mind, and & Histary of
the Pftseiona iind their Eflccts," London, Ut^S, voL L, p, 371.

APHABU.

169

1 lbert*fore asked for a cat (kazze)* Iii every word which had any*h0
flOimniited ti similar mbtake, substituttng a z for it«

He also cites, from Van Goens, the case of Madamo Hennert, wife
of the professor of mathematics at Utrecht, who suffered a similar de*
hct of memor}% When she wished to ask for a chair she asked for a
table, and when she wanted a book she demanded a glass. But, what
was siiigidar in her case was, that when the proper expression of her
tliotight was mentioned to her, she could not pronounce it*

She was angry if people brought her the thing she had named Iri-
»ti*iMl of the thiug she desii-ed. Sometimes she herself discovered that

had j^ven a wrong name to her thoughts. This complaint continued
feral months, after which she gradually recovered the right use of her
llection. It was only in this particular point that her memory
iMiiied to be defective, for M. Ymn Goens assures us that she con-
dneted her household affairs with as much regidarity as she ever liad
done, atid that she used to show her husband the situation of the heavens
on a map with as much accuracy as when she was in perfect health.

Tlie following case, in Gesner*s Endtckungen der ^^twakn ZcU in
dcr ArzneigfMrheitj is likewise quoted by Crichton:

** A man, aged seventy, was seized, about the beginning of January,
with a kind of cramp in the muscles of the mouthy accompanieil with a
jense of tickling all over the surface of the body, as If ants were rrcep-
ing over it. On the 20th of the same month, after having experienced
to attack of gifldiness and confusion of ideas, a remarkable alteration
ol htB apnech was observed to have taken place. Re articulated easily
tnd fitliettlly, but made use of strange words, which nobody understood.
Tk« Dumb<»r of these does not at present seem to be great, but thoy are
frequently repeated. Some of them he seems to forget entirely, and
tWn new ones are formed. When he speaks quick he sometimes pro-
nounees numbers, and now and then he employs common words in tlielr
propetT sense. Ho is conscious that he speaks nonsense. AYhat ho
writes is equally faulty with what he speaks. He cannot write his name.
The words ho writes are those be speaks, and they are always written
C4.iiifonmibly to his manner of pronouncing them. He cannot read, and
ftii many external objects seem to awaken tn him the idea of their
pwsence."

Dr. Rctshy' in the work the title of which is cited below, in chapter xii,,

h tn^ats o/ Derangemtiit in the Memory , refers so specifically to

^u^^tions of the speech that I quote his language with some degree of

tB0a6as, and I do so with the less hesitation as his observations appear

lo hsTe eacapcd notice, both in this country and in Europe. He says:

** L There is an oblivion of names and vocables of all kinds.

** %, There b an oblivion of names and vocables, and a substitution

'"^IMlral Incpirie) and Ohscrvationa iipou Di^eaae^ oftlic Mind.'* Fourth editioa.
rhUtddphit, IS3l}, p. 271. Tb« iret edition was published in UVl.

170

DISEASES OF THE BRAIN.

of a word uo ways related to thoin. Thus, I knew a gentleman afflicted
with this disease, who, in calling for a knife, asked for a bushel of wheat.

** 3. There is an oblivion of the names of stihstances in a vernacular
language, and a facility of calling them by their proper names in a dead
or foreign language. Of this, Wepfer relates three instances. They
were all Germans, and yet they called the objects around them only by
Latin names, Dn Johnson, when dying, forgot the words of the Lord's
prayer in English, but attempted to repeat them in Latin. Delirious
persons, from this disease of the raemory, often address their physicians
in Latin or in a foreign tongue.

** 4. There is an oblivion of all foreign and acquired languages, and
u recollection only of vernacular language. Dr. Scandella, an ijigenious
Italian, who visit-ed this country a few years ago, w^as master of the
Italian, French, and Englii^h languages. In the beginning of the yellow
fever which terminated his life in the city of New York in the autumn
of 1798, he spoke English only ; in the middle of his disease he spoke
French onlyj but on the day of his death he spcke only in the language
of his native country.

*' 5. There is an oblivion of the sound of words, but not of the let-
ters which conijiose them. I have heard of a clergyman in Newbuiyport,
who, in conversing with his neighbors, made it a practice to spell every
word that he employed to convey his ideas to them.

** 6. There is an oblivion of the mode of spelling the most familiar
words, I once met with it as a premonitory symptom of palsy. It oc-
curs in old people, and extends to an inability, in some instances, to
remember any more of their names than their initial letters. I once saw
a will subscribed in this way by a man in the eightieth year of his age,
who during his life always wrote a neat and legible band.

" 9. There ia an oblivion of names and ideas, but not of numbers.
We had a citizen of Philadelphia many years ago, who, in oonaequence
of a slight paralytic disease, forgot the names of all bis fiiends, bat
coidd designate them correctly by mentioning their ages, with which he
had previously made himself acquainted."

Dr. Rush remarks of these cases, that '* there appears to be some-
thing like a palsy of the mind, quoad these specific objects,"

Til us far there had been no attempt to define with precision the seat
of the faculty of language, or even to establish its existence; but, in the
early part of the nineteenth century, Dr. Gall, a German physician, an*
nounced that such a faculty did exist, and that it was seated in those
convolutions of the brain which rest upon the posterior part of the
Bupra-orbital plate, and that a large development of the organ was indi*
cated by prominence and depression of the eyes. He was first led to
believe in the ejcistence of such an organ by observing that some of the
scholars with whom, as a young nmn, he had to competep excelled him

APBASIA.

171

1 ability to learn by heart, and he noticed that those thus endowed
g^reat memory for words possessed prominent eyes. From these
circumstances, he was gradually carried on to the foundation of his

^nological system.

In reality, however, Gall considered that there were two organs of
ngc in each hemisphere — the one originating the idea of words,
thm other the talent for philology, and for acquiring the spirit of lao-
j^umgea. The former organ he describes as lying on t!ie posterior half
of llio 9upm*orbital plate, as before rnentiooed^ It gives a tak»nt for
leanun^ and recollecting words, and persons possessing it large, recite
loD^ passages by heart after reading tliem once or twice. The other is
pUoed on the middle of the supra-orbital plate, and when it is large the
eyeball is not only rendered prominent but is depressed, causing the
lowior cyeHd to assume the appearance of a bag or fuld» Persons having
tltis organ large have not only an excellent memory for words, but a
particular talent for the study of languages, for criticism, and in gen-
terms for all that has reference to literature.

Dr. Spurzlieim, however, admits but one organ, lying transversely
cm the posterior portion of the supra-orbital plate, and this view is ao-
oepied by Combe and other distinguished phrenological authorities.*

In support of his theory that there is such an organ, Gall cites the
caae of a notary reported by Pinel.' The latter, in speaking of apo-
plexy, says this affection may be limited in its action to the words which
mre used to express ideas. In the case mentioned, the patient forgot,
fif attack of apoplexy, his own name, that of his wife, those of

hi n and friends, although there was not the least paralysis of

Uii tongue. He no longer knew how to read or write, and yet his
» regarded other things was unimpaired.

Dc« Gall * refers also to the case of a soldier, sent to him by Baron
IjuTuy, who was affected in a manner similar to that of the notary. It
WMM not his tongue which was involved, for ho was able to move it
#b<>iil m all directions^ and to pronounce words, but he had lost the
mooiorj for words, although he recollected other things as well as ever.

I aliall presently have occasion to refer to a still more interesting
ease^ reported by Larrey, and one which appears to have escaped the
I of all writers on the subject of aphasia.

Sponheim mentions the case of one Lereard, of Marseilles^ who^
Wtih^ received a blow from a foil on the eyebrow (which one is not
•tftiwi), lost the memory of proper names entirely. He sometimes even
forgot th« names of his intimate friends, and even of his father,

^ F<or a fall &cccmtit of the tnl^eet, the render is referred to a ^* SjBtem of Fhrenol-
* bj Oeorfe Combe, Bottoo^ 18M, or to *^ Phrenology/* etc., br J. S. Bpurzheim,
1S39.

• •♦ TrailA tnidtoo-pbilofiophiquef sot I'ali^nation mentale.^* Second edition, F«m,
» p. Ml » " Phy$iologie da oervea<' tol iv., p. 84,

DISEASES OF THE BIUIX.

(

Gall, therefore, located the organ of language in a limited part
the anterior lobe of t*aeh hemisphere; but he adduceil very little e\i-
dence to support his opinionj and honce his views did not meet with
any thing hke general acceptance. A number of cases» however, re-
ported by Lallemandj Rostan, and others, support it, ivhile several ad*
dueed by the same authors are opposed to it.

In 1825 Oouillaud,* who had collected a great number of cases of
affections of the brain, was surprised to find how frequently the loss of
speech coexisted with disease or injury of the anterior lobes. He also
confirmed, what others before him had noticed, that the loss of the
power of expressing ideas in articulate language was often the only evi-
dence of a braiu-affection.

He made one very important step in advance, and his views on tins
particular point are adopted^ — and often without credit — by the mnjority
of the present writers on aphasia; he divided the faculty of speech into
two distinct categories of phenomena:

L The faculty of creating words as representatives of our ideas, and]
of recoUecting them — internal speech*

2. The power of coordinating the movements necessary for the ar*
ticulation of these words — external speech. ^

This classification fonns the basis of the division of aphasia into theH
two varieties, the amnesic and the ataxic, •

The cases which Bouillaud adduced ia support of bis theory were
many of them in patients who exhibited no other symptoms than the
loss of the power of articulate language. They preserved their intelli*
gence, comprehended perfectly questions put to them, and knew the
value of words; but, although there was no paralysis of either the
tongue or the lips, they were unable to utter a word. At the post-
mortem examination, the lesion was always found in the anterior lobes.
Sixty-four cases formed the basis of his conclusions. A part was direct^
and went to show that lesion of tlio anterior lobes was accompanied
by derangement in the faculty of speech; the other part was indirect,
and established the fact that, when the anterior lobes were not affected,
the lesion being in some other region of the brain, the faculty of speech
remained intact.

Cruveilhier opp»osed BouOIaud^ views, and, in a paper read at the
Ath<!*nee de Medectne in the same year, brought forward seven cases of
persons, some of whom had lost the facidty of speech, but who, on post-
mortem examination, were found to have no disease of the anteiior
lobes; and others who had spoken, but in whom there were more or less
profound changes in these parts.

Subsequently Andral * reported the results of the analysis of thirty*

' ^ Traits dtj l^encdphalite,^* PaHa^ 1825 ; miJ rIso^ *' Rechercbes cliaiqa^ propres 4
il^roontrer que la perto de U parole correspond h 1a 16sion de? lobules flnt6rit»ura da ecN
fcau»" ArthU't^ tir med.^ 1825. ^ '* Cllniquc midicaltV tome il, p, ISU.

APHASIA,

Rvcn cttses of lesion of one or both anterior lobes. Of these^ speecb
abolished twenty-one times, and preserved sixteen tiraes. Lalle*
maud' also opposed Bouillaud with several casea; but the latter rejoined*
with a fre«h array of thirteen cases in support of his doctrine, and with
many arguments against the validity of those brought against him.
Loaget ' dechires that Bouiliaud appears to have refuted many of the
objections of his adversaries, and to have demonstrated that some of
their cases were badly interpreted. At the same time, while adraittiiig
that it is possible that different parts of the brain preside oyer different
▼oluntarj^ movements, he affirms that there is nothing positively estab-
lished as regards the localization of the active principles of these move-
^nts.
Suhseqaently, in other memoirs, Bouiliaud brought forward addi-
Uoaal cases in support of his theory, making a total of one hundred and
e, and offered a prize of five hundred francs to any one who would
lace an instance of profound lesion of the anterior lobes without
iroubl«?s of speech. Many years subsequently Yelpeau announced that
should claim this prize, for that, in March, 1843, he had related the
e, and presented the brain, of a wig-maker who had come under his
Qftre for prostatic disease. This man was in full possession of his
rHisoning faculties, and, moreover, was noted for his unconquerable
IcKfuacity.. He died a few daya subsequently, and on post-mortem ex-
amination a scirrhous tumor was found to have entirely taken the
place of tlie two anterior lobes of the brain. Very little faith seems to
hare been put by physiologists or pathologists in the history of this
emse. If it proves any thing, it is that the anterior lobes are useless
appendages to the rest of the cerebral system.

But Bouiliaud was not content with the deductions to be drawn
from pathology. In a series of experiments, he endeavored to establish
the truth of his idea, and thus bring the science of physiology to his
jpport. These experiments were detailed in a paper * read before the
lemy of Sciences, in September, 1827, which %vas subsequently
published in the tenth volume of Magcndie^s Journal de Phydi-
from which I quote.
V^She experiments relative to the anterior lobes were made on dogs,
3y one was entirely successftd^ — the animals in the others dying too
soon after to admit of satisfactory deductions being made. But the
twentieth experiment was more satisfactory.

On the 28th of June, 1826, he passed a gimlet through the anterior

t Op. fit., Iclties 6, 7, 8.
*Ezpatltion dc aouTcaux tails k Vuppni de ropinlon qui tocallic dans led lobee ftu-
da ccrrcAU le pnnclpe l^gbltitcur de la purotc/' " BuUetiu do TAcad^iiide de
Ifldecitie/* 18^'J, tome Tt,, p. 282.

*Tr»iliS d«* la pliysiologie," toinc li., p. 438,

' Rwberchea exp^rittieat&le^ eur lc» fonctions du cervcmu (lobee ccrcbrftux) eo g^n^
I vi vur c«n«M de mi portion aut^rieure eo parttcuUer/*

1830)

DISEASES OF TilE BRAIN.

part of tho brain of an active, docile, and intelligent dog. Immediately
afterward the animal was conv^ulsed^ and could not rise from the ground.
Sight and hearing remained. Symptoms of compression soon came on;
tlie residt, probably, of the haemorrhage. Eventually, the animal re-
covered, but it was found to have lost much of its intelligence and
agUity* The faculty of memory seemed to have been entirely abolished,
and there was a decided expression of imbecility in its countenance. It
oould no longer ascend or descend a staircase; the fore-legs were lifted
very high m walking, and its movements were all badly courdimited.
When struck or made to walk, it uttered sharp crieSj but it had lost
entirely the ability to bark. As Bouillaud remarks, *'it no longei
barked, either to show its affection, or to drive away strangers who
came to the house*" Once only, on the 18th of July, it tried to bark at
a pasaer-by, but failed in the attempt.

This is the only experiment 1 have been able to find which has any
bearing upon the question of the localization of the faoidty of language*
And I do not quote it as proving much on the subject. The difficulties
in the way of experimentation are almost insuperable, to say nothing of
the fact that it is doubtful if any of the sounds made by animals can bej
compared with human speech*

But unintentional experiments have been performed upon the
human subject, which tend to show that, though the faculty of lan-
guage may be located in one or both anterior lobes, either may be
seriously injured without the faculty of language suffering to any ap-
preciable extent. Two of them have happened in this country^ and»
although referred to in connection with aphasia by Seguin and Harris,
I take satisfaction in bringing them forward on account of their great
importance to the question under consideration.

The first is related by Dr, Harlow/ of Vermont:

The subject was a strong, healthy man, twenty-five years of
and was engaged in ramming down a charge of powder in a rock to be
blastefl, when an explosion took place, and the tamping-iron was driven
clear througli his lioad-

In a few minutes he recovered his consciousness, was put into a cart
and carried three-quarters of a mile to his residence, where lie got out
and walked into the house. Two hours afterward he was seen by Dr,
Harlow. He was then quite conscious and collected in hb mind, but
exhausted by extensive hn'moj [lujj^.^ from the hole in the top of his
head. Blood, pus, and particli^j^ oi lirain, continued to be discharged
for several days, but by January 1, 1849, the woimd was quite closed
and his recovery complete. There was no pain in the head, but a queer
feeling, which he could not describe. As regarded his mind, he was
fitful and vacillating, though obstinate, as he had always been. Ho

i
I

^ Bottim MftUctil and ^arr/iW Journal, December, 1849, vol. xxxix., p. 889.
*^ Be&cdptiTe Catalogue of the Wnrran Anfttomicol Muaeum,*' Boston, 1870, p. 145.

A\m,\

APHASIA.

175

T^ry pfOtjBa"iiever having been so before the aceident. lie
lived till May 21, 1861, twelve and a half years subsequent to the acci-
dent, when he died, after having had several convulsions. His cranium
s obtained, and, with the bar, is now preserved in tlie Warren Ana-
aical Museum at Boston* Dr. J» B. S, Jackson * thus describes the
riraU:

"The whole of the small wing of the sphenoid bone upon the left
«ide is gone, with a large portion of the large wing, and a large por-
tion of the orbital process of the frontal bone, leaving an opening in
the base of the skull two inches in length, one inch in w^idth poste-
riorly, and tapering gradually and irregularly to a point anteriorly.
This opening extends from the sphenoidal fissure to the situation of the
(roataJ sinus, and its centre is an inch from the median line. The optic
(bmmen and the foramen rotuodum are intact. Below the base of the
ikun the whole posterior portion of the upper maxillary bono is gone»
Tli8 malar bone is uninjured ; but it lias been very perceptibly forced
Mitward, and the external surface inclines somewhat outward from
iboro downward. The lower jaw is also uninjured. The opening in
the baae, above descnbed, is continuous with a Une of old and united
fcmctufe that extends through the sujjra -orbit ary ridge in the situation
of tbd foramen, inclines toward and then from the median line, and
tcmtiiiati^ in an extensive fracture that was caused bj' the bar as it
cmmc out through the top of the head, llus fracture is situated in the
left half of the frontal bone, but inferiorly it extends somewhat over the
anedian line. In form it is about Cjuadrilateral; but it measures two and
m half by one and three-quarter inches. Two large pieces of hope are
mmm to have been detached and upraised, the upper one having been
<iep«ral«d at the coronal suture from the parietal bone, and being so
<sUMely united that the fracture does not show upon the outer surfac-e.
The lower piece shows the line of fracture all around. Owing to the
Joaa of bone, two openings arc left in the skull; one that separates the
mwo fragments has nearly a triangular form, extends rather across the
xnediati line, and is four inches in circumference ; the other, situated
^elWtfeti the lower fragment and the left half of the frontal bone, is long
^md irregularly narrow, and is two and live-eighths inches in circum-
Mmvoee, The edges of the fractured bones are smooth, and there ia
ftiowliere any ncfw deposit/^

Frum thia account it will be seen that the left anterior lobe of the
eiifferod severely by this terrible injury, and yet it is not stated
tho subject had ever shown any difficulties of speech. If the
Jly of language resides in the whole of the lobe, such an immunity
1 !M!arcely have existed. It must be noted, however, and the photo-
iph of the cranium establishes the fact, that the third frontal convo-
i and the island of Reil escaped all injur\% Another interesting
* DescripUf e CaUloguo of Wmreo Aaalomleal Mua4.Huu/' he, ctC

176 DISEASES OF THE BRAIN.

circumstance is the addiction to profanity after the accident. A like
phenomenon has been noticed in cases of aphasia.

The second instance is almost as extraordinary. I quote the history
of the case, 952, from Dr. Jackson: *

" Cast of the head of a man who was transfixed through the head by
an iron gas-pipe, and who, to a very considerable extent, recovered from
the accident.

"The patient, a healthy and intelligent man, about twenty-seven
years of age, was blasting coal when the charge exploded unexpectedly,
and the pipe was driven through his head, entering at the junction of
the middle and outer thirds of the right supra-orbitary ridge, and emerg-
ing near the junction of the left parietal, occipital, and temporal bones.
One of his fellow-miners saw him upon his hands and knees, and strug-
gling as if to rise ; and, going to his assistance, he placed his knee up-
on his chest, supported his head with one hand and Anth the other with-
drew the pipe. This last projected about equally from the front and
back of the head, and much force was required for its withdrawal"

Brain escaped from the anterior opening, and coma and collapse
supervened. " In seven weeks he sat up, and in one more walked about.
The right hand he used somewhat, but less well than the left. For
about ten months after the accident his memory for some things was
nearly lost, but during the next two months there was a considerable
improvement."

The accident happened on May 14, 1867, and in June, 1868, the
patient, with the gas-pipe, was exhibited to the Massachusetts Medical
Society. " The man appeared to be in a good state of general health;
and, though his mental powers were considerably impaired, there was
nothing unusual in his expression, nor would there be noticed, in a few
minutes' conversation with him, any marked deficiency of intellect."

It is very evident that in this case the right anterior lobe was
seriously injured — the left escaping — and yet there does not appear to
have been any aberration of speech. It is to be regretted, however,
that the history is not more specific as to the things in regard to which
the memory was deficient.

There are other cases which militate against Bouillaud's doctrine.
Thus, M. Peter ' states that a drunken cavalry-soldier fell from his hone
on the back of his head, and fractured his skull. Stupor set in at once,
followed by the most violent delirium. The man kept constantly shout-
ing the worst possible oaths, and held connected conversation with im-
aginary persons. He died at the end of thirty-six hours, without hav-
ing recovered his reason. On dissection, a fracture of the roof and base
of the skull was discovered in all its length. The posterior lobes of the

^ Op, «7., p. 149.

* Quoted by Trousseau, "Lectures on CliDical Mediciue.*^ Translated by Bazire, roL
i., p. 256.

APHASU.

177

Eld, on post-mortem exatniuutioiij to have sustained no
IT, but both anterior Jobes were in a pulpy condition, through a
' most \*ioIent contusion, caused by their being knocked against the an-
terior wall of the cranium. The whole thickness of the lobes was dis-
organized* As Trousseau remarks, this case shows that the two frontal
lobes may be destroyed in their anterior portion without causing a loss
d the faculty of speech* Trousseau also cites the case of two officers,
who, after a quarrel, fought a duel. One of them fired first, and the
UU entered his adversary's head at one temple, passed through the
hmin, and then raised the temporal bone on the opposite side* The
kll was extracted, and the patient immediately made a sign with bis
hudtt, and expressed his thanks in a very low voice. He recovered, for
fhi time being, and, during five months thereafter, could speak perfect-
ly^ ^ I was remarkable for the wit and fluency of his conversation
1^ ^\ He subsequently died of softening; and it was found, on
! 1 mortem examination, that the ball had passed through the two
ir 1 ,1 J Jm's in their middle portion. A still more striking case is re-
ft rr 1 t > ir» Dr. Bazire, in a note to Trousseau's lecture on aphasia, in
tke wnrk cited. It was reported in 1843 by M. Aug. B<&rard, to the
AimomicaJ Society of Paris. The patient, a miner, was knocked down
in»l severely injured by an explosion in a mine. He did not lose oon-
uena, but managed to creep out of his hole and to call to his help
f men who were working a short distance off. Ho begged them to
fctdi t cart and to t^ke him to M. Berard's house. He was there ex-
wained. The whole frontal region was laid open, the integuments hung
Ki Ai^dt, the bones were splintered and in detached fragments, and the
liUQ was exposed. Both anterior cerebral lobes were completely de-
"'^y^d, and in their stead was a mixture of blood, of bony splinters,
^tkil bnin-#ubstance. In spite of this frightful injury, the man could
n all its details how the accident had occurred. He died the

^Vh«th<ir or not we accept this case In all the import claimed for it,

' ^t that Bo nil laud is wrong in claiming that injury

IS necessarily followed by some derangement in the

^w^tlty of Rpooch. It is only fair, however, to state that latterly he has

^^ ' f-'d that the oj^n of language may occupy the posterior part of

■ :■ lube.

l>r, hL Dax, in 1830, read a paper before the medical congress which
^n thut year at Montpellier, in which he came to the conclusion that
il» fatniUy of language '* was seated, not as Gall and Bouillaud had
^^tttnded, in both anterior lobes of tlie brain, but that it occupied only
'"* Uh anterior lobe.'' He based this opinion on one hundred and
'*^y casei of apb&sia attended with paralysis, and in which the loss of
P^^er was on the right side; showing, therefore, that the lesion which
p^uc^ the aberration of speech also caused the hemiplegia, and that

178 DISEASES OF THE BRAIN.

this lesion must have been on the left side. This paper at the time at-
tracted very little attention, and was forgotten till the year 1861 wit"
nessed the reopening of the discussion/

It would be very easy to quote a large number of cases confirmatorji
of Dr. Dax's doctrine, but a few will suffice to show the general bearing
of a great many others. The following case seems to have escaped
notice. It is not the one referred to by Gall as being sent to him bji
Larrey. In that case the left anterior lobe was injured and there was
aphasia, but the lesion was caused by a sword.

Baron Larrey * presented to the Academy the cranium of a subject,
with the following history:

Toward the end of the year 1815 an officer of dragoons came to the
hospital with a wound from a ball which he had received at Waterloo.
The missile had entered the left side of the cranium at a point aboul
six or eight millimetres from the eyebrow and near the temporal ridge.
At first he had suffered loss of consciousness and profuse haemorrhage,
but had recovered, with but slight loss of motor power. So far as hia
mind was concerned, there was no derangement except as regarded the
faculty of speech ; he had lost the memory of substantives. For t\m
reason he was unable to drill his company, and, though able to distin*
guishhis men by their size, their form, their complexion, or their voice,
he could not call them by name. He refused to allow the operation of
trephining to be performed, and in 1827 died of phthisis.

A post-mortem examination was made. The ball was found em-
bedded in the thickness of the bone, having elevated and fractured the
internal table. The dura mater was strongly adherent to the whole oi
the left anterior cranial fossa; it was also thicker and denser than in the
natural state. A spheroidal excavation, five centimetres in its horizontal
and seven or eight in its vertical diameter, was discovered at the summil
and on the temporal side of the left anterior lobe of the brain.

Mr. Thomas Hood * reported the history of a patient, a sober, intel-
ligent man, sixty years of age, who, on the evening of September 2,
1822, suddenly began to speak incoherently, and became quite unintelli-
gible to those around him. It was discovered that he had forgotten the
name of every object in Nature. His recollection of things seemed tc
be unimpaired, but the names by which men and things were knowi!
were entirely obliterated from his mind, or rather he had lost the faoult}
by which they were called up at the control of the will. He was by nc
means inattentive, however, to what was going on, and he recognized

' Dr. Marc Dax*a memoir was republished in the Gazette hebdamadaire. No. 17, April
1865.

• " Blessure du oerveau avec perte de m^moire des noms substantiyes," Journal d
phyiiologie de Magendie^ tome viii., 1828, p. 1.

• " Phrenological Transactions." Quoted by George Combe in his ** System of Phre
nology," Boston, 1884, p. 429.

APHASIA.

I and ftit^Hlinfifcnces perhaps as quickly as on any former occasion;
but tbeir naiDila(«^ even his own or his wife*s name, or the mimes of any
of bi« doin^-sUcs, appeared to have no place in his recollection.

•* On the morning of the 4th of September," says Mr. Hood, " madi
Utisi the wishes of his family, he put on his clothes and went out to
the workshop, and when I made uiy visit he gave me to understand, by
itariety of signs, that he was perfectly well in every respect, with the
vaepliim of some slight sensations referable to the eyes and eyebrows.
Iprerailed on him with some didicalty to submit to the reapplication of
IttobeSy and to allow a blister to be placed over the left temple. He
wnow so well in bodily health that he would not be confined to the
loQsii and his judgment, in so far as I could form an estimate of it, was
vmaipaired, but his memory of words was so much a blank, that the
ai0nofyllables of alfirraation and negation seemed to be the only two
words in the language the use and significance of which he never en*
tiii'Jy forgot. He comprehended distinctly every word which was spoken
Of julilrrssed to him; and, though he had ideas adequate to form a full
f^ply, the words by which these ideas are expressed seemed to have
Wa entirely obliterated from his mind. By way of experiment I would
*" Mention to him the name of a person or thing, his own name

f-' ^ , or the name of some one of his domestics, when he would
Wp»t it after me distinctly once or twice; but generally before he could
fc*oa third time tho word was gone from him as completely as if ho
Mn^vwr beanl it pronounced. When any person read to him from a
^k, ho hail no dil^iculty in perceiving the meaning of the passage, but
lit could Dot himself then read, and the reason seemed to be that he had
f<^rgotti^a the elements of written language, viz., the names of the let*
**» of the alphabet. In the course of a short time he became very ex-
pen ia thie use of signs, and his convalescence was marked by his im-
P^'^o^i'dhtf acquiring some general terms which were wnth him, at first,
^^"WTfit«nsive and varied application. In the progress of his recov-
^fy» timi? and space came both under the general application of time.
«« future events and objects before him were, as he expressed it, * nexi
'^^/* but past events and objects behind him were designated * /cM^
*'"*^' One day, being asked his age, he made me to underatand that
« ocittltl not tell; but, pointing to his wife, uttered the 'wnrds, ^ many
***••' repcmtodly, as much as to say that he had often told her his age.
^^■•Q the antwejn^l sixty, he answered in the affirmative,"

^ the 10th of Jatmary he suddenly became paralvtic on the left
^^^ [thig is evidently a typographical error for right side]. On the 17th
**' AttgFiiat he had an attack of apoplexy, and on the 2I«t he expired.
*** %t Phrenological Journal^ vol, iii., p. 38, Mr, Hood has reported
^ dissection of his brain: " In the left hemisphere, lesion of the parts
*■» found, which terminated at half an inch from the surface of the
wiia, whrre it rests on the middle of tho supra-orbital plate," Two

180

DISEASES OF THE BRJUK.

small depressions or cysts were foiiiid in the substance of the bn
** and the cavity considered as a whole expanded from tlie anterior part
of the brain till it opened into the ventricle in the form of a trumpet.
The right hemisphere did not present any remarkable appearance*"

Dr. Thomas Hun,* of Albany, in detailing a case of anmesia in
which there were no symptoms of paralysis, and in which there was
no post-mortem examination, cites the case of a lady who died of cancer^
of the brain, occupying, at the time of her death, the greater portioQ
of the left anterior lobe. In the early stages of her disease she waal
often unable to call the most familiar objects by name, and had to ex-j
press herself by signs or by pointing at the object. When the
she wanted was pronounced before her, she reoognized it, and was ablol
to ropeat it.

Other cases, and especially several which have occurred in my owa \
experience, are resented for future consideration*

Up to this period we have the organ of articulate language limited
to (he left anterior lobe of the brain, but in 1861 its location was still|
further restricted. In that year M. Gratiolet, in discussing before ike I
Anthropological Society of Paris a question relative to the comparative 1
development of the brain and mind among different races, brought up <
the subject of cerebral localization, to which he announced himself
being strongly o|>posed. M. Auburtin, on the contrary, contended tliat|
the localization uf the faculty of speech at least was definitely estab-
lished, through the researches of Bouillaud, in the anterior lobes. In
support of this view, he adduced cases wliicli had already been brought
forward, and cited others in addition, which went to show that loss of
speech was the consequence of traumatic lesion of these parts of the
brain. His adversaries cited other cases in which persons hjid presenred i
the faculty of language notwithstanding extensive lesions of the ah^
tenor lobes, M. Auburtin responded that, if such profound and extea*^
sive injuries had not interfered with speech, it was because that part of]
the lobes in which the organ is situated was not involved. And he then [
cited the case of a patient in the Hospital for Incurables, who for many I
years had been deprived of the power of speech, and he declared that 1
ho would renounce the doctrine of Bouillaud if tlie autopsy of this I
patient did not reveal disease of the anterior lobes. The patient in
question was under the charge, of M. Broca, and the latter, a decided J
opponent, accepted the challenge of M. Auburtin, and declared that^l
when the man died, the examination should be made.

Some time afterward the patient died, the post-mortem examination I
was made, and the lesion was found to occupy the left anterior lobe.*

From this time forward, >I. Broca, who had been a most determined i

^ Am0i4can Journal of JnManity, vol. vii,, 1850-^51^ p. $09.

' See ^* £tudc Bur U loaiU&iitiotL do U faculty da langiige articuU/^ Tlidse de Puis
d«s M. Canier, IS67.

APHASIA.

181

iiillautrs views of localization, became converted, dnd
CMxicd tliein to a still more extreme point than even M. Marc Dax had
done* Tiking, as his principal case, the one to which M. Auburtin had
jdtrned his faith, he read, in 1861, before the Anatomical Society of
Pmis, a memoir,* in which he discusses the question of the location of
s in question with all his perspicuity and directness. As tho
cited bj him are of historical interest, I give the chief details
o( tbem:

A man named Le Borgne, who had been an inmate of another de-
pMtment of Bicetre for over twenty years, was transferred to one of
the wards under M, Broca'a care, to be treated for a severe attack of
pUeginonous erysipelas. The man was a confirmed epileptic, and had
not spoken, since his entrance into the hospital, more than a few wonls,
wliith he employed for the expression of all his ideas. It is stated that
)fi other respects his intelligence was good, Le Borgne was known in
the hospital by the name of " Tan," a word which he habitually used,
AaJ which| with the oatli, ** Sa**ri nom de Dlen^^ constituted his entire
toc*balary. ''Tan,'* owing to the copstancy with which he used it, was
^ name by which he was known in the hospital; and^ when he could
<^ make himself understood by his aigns, he employed the oath, and
£^Te other manife-stations of angen

For several years he had remained in tlie hospital with no other

*">iotl than that of speech, with an occasional epileptic paroxysm j but,

***^ A few years, his right arm became paralyzed, and four years sub-

'•^'pieatly the leg of the same side was involved; his sight was likewise

^fe^bled, and for the past seven years he had been entirely confined

^ his bed,

^iotwttlistanding the fact that he was almost in a dying condition
^h<»tt M, Broca first saw him, some important points in his cerebral
'^^iSctilty *rere noted. To any question put to him, ho replied, as usual,
^un^ but at the same time endeavored to make himself undexstood
°3r mgOA^ llius he raised six fingers to indicate that six days had
**^{»«id since the inception of his erysipelas, and by opening and shut-
^>x^ his hand four times and then raising one finger signified that he
"*d been twenty-one years in Bicetre.

Seosibility was lessened on the affected side^ there was no deviation
^ tie tongu<-% which eouid be moved freely in all directions, and no
fttllysia of the faoe beyond a slight weakness shown by the swelling of
4e left side when he breathed; there was a little difiiculty of swallow-
^ froni tbo fact that the muscles of the pharynx were gradually be-
Oomiiig^ implicated. After a few da^'s the man died,

Aa I have aaid, the autopsy showed that the lesion waa sitoated in
llkf \td% anterior lobe. More exactly, however, it should now be stated

* **8«r ta ^4ige de la faculty d« lungag? artlculS tree deux obdcrrationt d^apbemia**'
if U m€iiii amaivniqm^ tome i?^ 1861.

182

DISEASES OF THE BBAIK.

that it involved tlie inferior marginal convolution of the temp
sphenoidal lobe, the convolutions of the island of Reil, and in the fron-
tal lobe, the frontal transverse convolutionj and the posterior half of
the second and third frontal convolutions. Tlic left corpus striatum
was also affected. According' to Broca, the disease had in all probabil-
ity begun in the third frontal convolution, and had gradually extended
to the other parts; the paralysis marking the implication of the island
of Eeil and tlie corpus striatum.

The other case was that of a man named Le Long, aged eighty*four
years, who had entered the hospital for a fracture of the neck of ih©
femur. Eighteen months before, he had been treated in the medical
service for a temporary apoplexy, which had deprived him of the faculty
of speech, but had caused no paralysis, I^ ^"^j whose intelligenoa,
facial expression, and ability to gesticulate, were very striking, made
himself perfectly well understood, although able to pronounce indistinct-
ly a very few words, but which were nevertheless properly applied.
These words were "o?*i," **^iOfi, ioujours^ toW^ for trois^ and J^elo for
jLe IdOhfj, Thus when askod, ** Can you write ? " he answered, •* OuL**
« Have you any children ? "" " Qui.*' " How many ? '' " Tois,'* but at the |
same time, as if aware that he was not answering correctly, be raised
four fingers, ** How many boys? *' **Tois," raising two fingers* **How
many girls ?*' " Tois," holding up two fingers. ^^ What time is it by this
watch?'' "Toia," at the same time raising ten Angel's to signify that
it was ten o'clock. " How old are you ? " To this question ho replied
by two gestures \ the one consisting of raising eight fingers, the other
of four fingers, by whicli he meant that be was eighty-four years old.

Aside from this application of the word tois to all numbers, his
answers were perfectly correct. The tongue was neither paralyxed oar
thickened; on one side the larynx was mobile, and his limbs possened
their normal power for his age. It was therefore a case of pure aphasia,
or, as Broca then designated the affection, aphemia.

Twelve days after the accident, the patient died. The post-morten
examination revealed the existence of lesions, almost identical in situa-
tion with those of the fonner case, Tlie posterior part of the third left
frontal convolution, and the contiguous part of the second, had been
absorbed and replaced hy a serous fluid* Two caaea can scarcely decide
any point in pathology; but, without venturing to assort positively that
the organ of language resides exclusively in the posterior part of the
third frontal convolution, M» Broca expressed the opinion that the in-
tegrity of this convolution, and perhaps of the second, is indispensable
to the nonnal operation of the function of speech.

Many cases were adduced by Charcot,* by Falret,' by Perroud *

1 Oiorn^ Mdomadain, 1863, pp, 4TS, 525.

• Archivmik mideeinf, tome iv., Mi»ra et Mai, 1801,

' Journal de mSd«ein« de Lifon^ Janvier et F^'vricr, 1864

APHASIA.

188

fTOfia, by Trousseau/ and others, in support of the localization of the
faculty of articulate language? in the left side of the brain. Most of
thesd cases were accompanied by right hemiplegia, and, in several, post-
mortem esaminatious showed the lesion to exist in the parts designated
by Broca,

In the early part of 1833^ M. G. Dax, son of the M. Dax who bad
plAced the organ of language in the left hemisphere, presented, through
M* Lfslut, a memoir to the Academy, in which he claimed with his father
lli&t aphasia was always the result of lesion of the left hemisphere, but
lie assigned a still more restricted position, by limiting it to the anterior
and exterior part of the middle lobe. He cited forty cases of loss of
the power of speech, coincident with lesion of the left hemisphere.

Now, besides these direct ca^^^es, there are others which bear w*ith
almost as much effect on the aflSrmative of the doctrine in question.
Thus M. Fernet, in 1863, presented a case to the Soci^t^ de Biologie, in
which there was left hemiplegia, but no aphasia. After death, soften-
ing of tlie right hemisphere, from thrombosis of the right middle cere-
biml artery, was found to exi^« ^I. Parrot * adduced another case in
which there was complete atrophy of the island of Reil, and of the third
COnTohition of the right aide, but in which tliere was no trouble of
speech. These cases go to show that the organ of articulate language
is not Mtuated in the right hemisphere.

M. Lesur * has reported a case which is of very great interest. A
child was kicked on the head by a horse, and a fracture of the frontal
bone was thus produced. The operation of trephining was perfoiTued
at a point about an inch and a quarter above the left eye. After the
operation and during the progress of the case, it was observed that,
whenever pressure was made upon the brain through the hole in the
oramum, the chdd lost the power of speech, and that when this pressure
wwrn lemoved she regained it. A similar case occurred several years ago
in my own practice.

Among British writers, Dr. Hughlings Jackson * has given the histo-
ries of thirty-four cases of loss of speech coinciding with right hemiple-
gia, lie is entitled to the credit of making a beautiful application of
anatomy and physiology to the patliology of the subject under considera-
liofi* The part of the brain designated by Broca as the seat of the
organ of articulate language is nourished by the left middle cerebral
mttery* An obstruction of this artery would of course interfere with
th' ' t action of that region, and thus aberrations of speech would

bt' _ d. But the same artery also supplies blood to the corpus

striatum of the same side. Hence the frequency with which aphasia is
■MM^t^ with right hemiplegia. The cause of the obstruction is gener-
^^H^pecording to Dr. Jackson, embolism, for in twenty of his cases the

^^■^ I Climque mSdicatt, > Gazette hfbtlomadaire, 1863, p. 506.

^^H < OtuetU dm Mpiiawc, * *' Lou don UoiiptUil Reports,*' vol. I

184

DISEASES OF THE BRAIN.

heart was more or less affected, and ia thirteen of them there was valVii''

lar disease.

Among other British writers, some of whom will be more fully re-
*ferred to hereafter, must be mentioned, Dr Sanders,* Dr. Moxon,* Dr.
Ogle,' Dr. Bateman,* and Dr, Bostian/

The matter does not appear to have attracted much attention from
German physiologists and pathologists, since the discussion in the
French Academy in 18GL Previous to that period several es:0QU6iit
memoirs upon the physiology of speech wore published by Germaxm,
among which that of Dr, Bergman ' is preeminent. A memoir by Naaao
is also interesting.

In 1865 Von Benedict and Braunwart ' published a very thoroi
paper on the subject, and other observers have reported cases.

In this country there have been several veiy excellent memoirs upon
aphasia, and, as we have already seen, the subject early attracted atten-
tion, and the fact that such a condition could exist without other mam*
fcst symptoms was fully reeogni2:e»L Thus Prof. A Flint • detailtnl tlie
histories of six cases, in one of which po^-raortera examination showed
extensive disease of the left anterior lobe, and in four, in which the
situation of the hemiplegia was noted, tlie right was the affected side.

Dr. H, B. Wilbur,** in a memoir on aphasia, treats of the aberrations
of the faculty of language as they exbted in certain idiots under his
observation. His cases, though interesting, are scarcely in point, as the
diJhcultics of speech were clearly the result of mental deficiencies,

A very important memoir is that of Dr. E, C Seguin,^* in which a
very excellent history of the subject is given, with the citation of forty-
eight cases from the records of the New York Hospital, in which there
were difficultiv^s of speech coexisting with hemiplegia, and two in which
there was no hemiplegia. In several of these cases, however, as Dr,
Seguin states, the loss of the faculty of speech was due to paralysis of
the tongue and other muscles concerned in articulation.

Another excellent paper is by Dr. T, W. Fbher," of Boston, Dr.
Fisher has studied the subject very pinlosophically, and records thirty-

' Edinfmrr/h }fi'dlcnlJQHrryil^ Auj^al^ 1856,

' BritUh and Foreign Mcdico-Chirur^lcal Revkw^ April, 1S(S0.

« "St George's Hospital Reports," vol ii., 18ti7.

* Journal af Mt-nttd Science, January, XS*i8, and aubsctiuent numbers.

* BHihfh and Foreign Mtdu^Chlhirgical Rmnt^e, Juiumrf iitid April, 18459.

• ** Eiaige Bemarkungun uber Storungou disa GcdiwUtttUa uud dcr Spridie. AU^
moiW Znfsc/iri/l fuf PHtfchiatrle, 1849, *, 657.

' AUjjfemeiM ZiiUthrift u, s. w,, 1853, s. 523,
" CftusUUt*s *' JaUrc^bencht," lBf.6, s. 81,

♦ Medical Record (Ne«r York), March 1, 18«*5.
*" Attu^ricnn Joufnal of iHittinltt/, July, ISi'it*

^* Quartcrltf Journal of Pti/cholof/li^al Afedkine^ el<^„ Jantmry, 18G8.
1* BostQii Medical and Surgiad Jotinmt, Si^ptcmbcp 1, 187D, and subsequeat aiual

185

e^giit OAses in wHch post-mortem examinations were made with definite
results. Cases have also been published by Bartholow * and others.

With this outline statement of the history of the subject of aphasia,
we are in a position to inquire more fully into the evidence whic^h locates
ibo organ of language in a particular region of the brain.

A clear idea of the anatomy of the parts fixed upon latterly as the
aeat of the faoultj will aid in the understanding of the subject.

The following account is condensed by Dr. Bateman ' from Broca's
do9cription in his essay "Sur le siuge de la faculty du langage arti-

**The anterior lobe of the brain comprises all that part of the hemi-
fl{diere situated above the fissure of Sylvius, which separates it from the
temporo-sphonoidal lobe and in front of the furrow of Rolando which
dirides it from the parietal lobe. The furrow of Ilolando separates the
frontal fit>m the parietal lobe; it traverses from above downward all the
external surface of the cerebral hemisphere, starting from the inter-
liemispheric median fissure, and ending at the fissure of Sylvius. In
front, this furrow is bounded by the transverse frontal convolution, and
behiod by the transverse parietal convolution. The anterior lobe is
oomposed of two stories or divisions — one inferior or orbital, the other

|IVnpt»l C<ift\^nttoiJ ; 3. S«eond Froo!«l Confolntion ; 8. ThW Frontal Convolution ; O. Orbt-
^^volulioQ*; E F, TmifTeno Ftontol Conrolation; P. PiiH«UI I^txi; T 8, Trmponnpb*.
\ Loti«: T 1. First TMnporO'tpheDolrlnl CoovolacirtQ; T t. Second Temporo-spbejialaAi Ooqto-
l Ulw>dofU«y; Sk rurowofKolaDdo; 8. Fismre of SjMoa.

superior — situated beneath the frontal and under the most anterior part
of the panetaL Tins superior division of the anterior lobe is composed
of four fundamental convolutions; one posterior, the others anterior.
The posterior is that which has been described as the transverse frontaij

» JIMita! Hepertoty^ CTmciaaftti, Januapy, 1859. • Op, dl^ p, 521

18C

DISEASES 01 THE BRAIN.

and which forms the anterior border of the furrow of Iloknilo; the i
other convolutions have all an antero-posterior directiou and are distin-
gaished by the names of superior or Jirst frontal^ middie or second, and
inferior or third frontal convolutions. This last| by its posterior half,
forms the superior border of the fissure of Sylvius, the inferior border
being formed by the superior convolution of the temporo-sphenoldal
lobe. In drawing asunder these two convolutions which bound the fis^
sure of Sylvius, the lobe of the insula (the isknd of Heil) u exposed,
which covers the extra-ventricular nucleus of the corpus striatum. The
result of these relations is that a lesion, which is propagated from the
frontal to tlie temporo-sphenoidal lobe, or vice versa, will pass almost \
necessarily by the lobe of the insula, and thence, in all probability, it '
will extend to the extra-ventricular nucleus of the corpus striatum, see*
ing that the proper substance of the insula, which separates the nucleus
from tlie surface of the brain, is composed only of a very thin layer."

The lobe of the insula, or the island of Keil, is found in no otlnir
mammal than man and the monkey. In the latter, however, it is very
slightly developed, and has no trace of convolutions. In aberrations of
speech this part is very often involved in the lesion.

Now, although there are several oases on record in w^hich post-mor^
tern examination would appear to show that lesion of the third left
frontal convolution is sufficient to produce derangement of the facultr
of articulate language, the weight of evidence is decidedly against limit*
ing the seat of the organ to this part. Thus, of five hundred and fifty-
six cases of aphasia tabulated by Seguin,' the third frontal convolution i
was damaged but in nineteen. While, therefore, we must admit that j
injury or disease of this limited region will cause aphasia, it is going J
too far to assert that the lesion must exist in this situation in order that
aphasia may be produced. Moreover, Segtun gives another table of I
eases which must definitely settle the matter, and which I quote isx fuJLJ
It relates to autopsies which were made with special reference to the 1
point in question, and in which the details given were sufficient clearly*
to indicate the location of the lesion.

QUESTION OF THIRD USXT FRONTAL COXVOLUTIOX.

AFTHORITTES.

TtrooftMan, 1865 (in Aead^mie d^ M6dtVme)

Peter, Legrnnrl, Boclardj Delpech, Bdrard^ li'argc, Jncksoo,

Btgctow 4. « . *. ...«*••«•#«*

Jftckson, KU'btinlson, Hu»sel.. « •«.«■•.

New York Uuspital, l83fU^67. .

Bellevuu Hospital, October, 18«7 •

Total ,..__,, ,

Tof,

Agatoil*

^Cp.tAL^'p. 97.

APHASIA,

187

c&ies might readily be adduced, but the above are amply siif-
fioient to decide the question against Broea's doctrine. One case of
i^iliasia occurring without lesion of the third frontal convolution woidd
of course invalidate his claim that this part is the exclusive seat of the
org«n of language, and no number of cases showing coexistence of
aphajsiA with disease or injury of the third left frontal convolution would
be suOicii^nt to establish the point affirmatively with the results of our
present experience disproved. Nevertheless, as showing further that
disease of this part will cause aphasia, I subjoin the following case from
Dr. W. Ogle^a* veTj interesting memoir:

•* Joel R, October 18, 1866. Had rheumatic fever and endocarditis

filty-five years ago, but since that has bad good health. While at

k, October 15th, fell down suddenly without losing consciousnesSj
mnd found that he was speechless, and hemiplegic on the right side*

" On admission he was found to have extensive heart*disease, with
the pulae characteristics of aortic regurgitation. There was complete lax
palsy of the right arm and leg, with unimpaired sensibility. There was
at first some dilTieulty in deglutition and ia protruding the tongue, but
this latter symptom passed away in a few days« There was slight pain
in the left side of the head,

" His speech was limited to the two words * yes ' and ' no,* These
be used correctly. After he had been in the hospital some time, he
recorered the power of saybg some few words, chiefly monosyllables.

"He could write with his left hand, with sufficient distinctness,
words which he could not pronounce when asked to do so. In his writ-
ing there was often a tendency to reduplication of letters. For instance,
lie wrote ' Testatament ' for * Testament,' But I cannot say whether
thsM was more than the result of deficient education.

**His mind seemed quite clear. He understood all that was said to
him; took interest in all that was going on about him; listened to con-
Tenation with an animated, lively lookj laughing at any little pke, and
expressing himself frequently by suitable pantomime. In December he
was attacked by oedema of the lungs, and died on the 20th,''

Pottt-mortem, — (Kdematous lungs, extensive aortic and mitral disease,
** Much semi-gelatinous fluid in subarachnoid space. Surface of brain
healthy, excepting at one limited spot. This was the posterior part of
the third frontal convolution on the left side. Here was a softened,
almoot diffluent patch about three-quarters of an inch in breadth, reach-
ing from the highest point of the third convolution backward and down-
wanl to the fissure of Sylvius. Tlic softened patch was not actually
the most posterior part of the convolution, for there was a narrow un-
8^ftene4 strip between it and the transverse frontal convolution. In
, CQttiog into the brain, a second small patch of softening was seen in the
ih eenlie of the left hemisphere, external to and rather above the corpus
B ^ **ApbiiU tad AgnphiA/' *'St. G(^orge^fl Hospit&l R{*port9," vol il, 1807| p. 10&.

^
I

18S

DISEASES OF THE BKAIN.

strlattim, and extending toward the posterior termination oi tue assure i
of Sylvius, All the rest of the bra.in was apparently healthy*

"The left middle cerebral artery was firm in its main trunk, but in
one of its secondnry branches at a bifurcation was a hard sbotty bit of
fibrine completely obstructing the passage, so tlmt when water wag in-
jected into the vessel it could not pass, though considerable force waa
used. There were also fibrinous blocks in the spleen,"

The theory of M. Marc Dax locates the faculty of 8pc€<^b in the
left hemisphere. He based this opinion upon the fact that aphasia
is associated almost, if not invariably, with right hemiplegia, when
there is any paralysis at alL That this is really the case is beyond
question. Without, however, referring again to the case^ cited by M,
Dax, I quote the following table from Dr. Seguin's paper:

AFHASDL WITH HEMIPLEGIA*

AUTEOEITIES

Trou^deau, lS6fi ^Aettdeinii^ de M^decine) , , , ..

Baillarger» later in 1866 (Sjilpfilri^re) .

Jack^ODf loc. cit * *

Robertiion, loc, cit .,,..,.,.

Mcdlml Tillies und Gazotte, 8«ptcmbi*r 9, 186&.

Archives Geni^ram de M^dmiie, 1866

Flint, New York Mediml Record, ?oL L

Haw York Hospital, ISSO-'GT.

Total

Bl«rbt

SiS

From this table we learn that, of two hundred and sixty cases
aphasia associated with paralysis, the left hemisphere — as determined by!
the situation of the hemiplegia — ^was the seat of the lesion in two bun-
dred and forty-three cajsips, and the right in only seventeen.

I also quote the following table from Dr. Seguin ;

QUESTION OF LEFT ANTEBIOB LOBE.

AUTOPSIES BY

Marc DiLXf ia 1661, and Q. Dax (Acad^iiiie de M^dedno,

lHfi3|

Bouillftud, 1848..

1865

Tronsseftu (Acftddmie de M^decinc).

Vulpian {I^^qub de Pbv^^ioloj^if) , . . ,

New York llospiml, 183r»-M7

Jackson, Ritliur<l!*on, A, Clark, 1806-^67 , . , ,

Peter, Legnrnd, Boclarfl, Delpeeh, Berani, one eadi

Farge, lJi^eli>Wj Detmold, uud Stokee, one each

Total

For,

AxsiEtft,

This table is based on autopsies, and may be considered conclusive

APHASIA.

189

WtOtb^^Rfive frequetloy with which aphasia is connoeterl with dis*
mi6 f>f the left anterior lobe.

Ffotn %iirious sources I have obtained the following additional cases,
ta which the seat of the lesion was determined either by post-mortem
ition or by the situation of the hemiplegia:

ADTHORmES.

Lrft

Klifht

b"- ^ ,.....,

6
SO
15
25

• •

I„ ^ .._.

M. •.►■i,

limhnloir^ ..,^ ,, ,,»

Mkicaiu) *

W.WmUuMn. ,.

Total..

The immense preponderance of disease of the left hemisphere, and
'■■■• ( its anterior lobe, as a concomitant of aphasia, is therefore

[ itul a doubt. Indeed, so far as I am aware, the fact is not

<3Ui5«tione<i How, now, is it to be explained ?

Wc cannot claim, even with all the disparity of cases, that the organ
^t l&ngiia^ is located in the left anterior lobe, or even in the left heini-
"phere, to the exclusion of the other. Broca has attempted to account
hr the assumed restriction, on the ground that the left hemisphere ro-
c*»iv©s a krger supply of blood, and is earlier developed than the right.
"Hita 11 doubtless correct, but still the fact remains that lesion of the
%bl heoiisphere is sometimes followed by aberrations of speech; the
itDuuning perfectly healthy. One such case — and there are several
in wliich the autopsy confirmed the deductions drawn from
Bptoms — is hufllcient to overturn the theory which restricts the
tlttiiitJon to one side of the brain; and one such as that reported by Dr,
itoipiion,' in which there was extensive lesion of the third left frontal
*^'tivolution in its posterior part, and no epilepsy, paralysis, or aberra-
of speech, is of course utterly destructive of Broca's views.
Tlie fact that aphasia is more frequently conjoined with right hemi*
it undoubtedly due mainly to the fact previously insisted upon in
' vs on cerebral embolism, that the left middle cerebral arterj^is
to liable to be plugged by an embolus than the right; and it is

V vmbolkm that aphasia is generally caused. Dr« Hughtings Jackson *
■•• Vftry sstisfactortly worked out the relation, and my own experience,
P^^^ntJy tci be related, abundantly coulirma the fact.

At the same time it appears to be clearly shown that the left anter

« Utdical 'nmn and OoiHie, December 21, 1867.
t ** Loudon Hospital Reportu,'^ vol I, he. Hi,

190 DISEASES OP THE BRAIN.

rior lobe, or rather, in accordance with Dr. Jackson's views, those parts
of the brain nourished by the left middle cerebral artery, are more in-
timately connected with the faculty of articidate language than any
other region of the encephalic mass. It is probably true, as originally
advanced by Dr. Moxon,* and since urged by Dr. William Ogle," that
the organ of speech is to be found in both hemispheres, and that one
side is more generally employed than the other, just as we ordinarily
give a preference to one eye or one ear or one hand, and that this side
is the left. Gratiolet's facts, adopted by Broca to support his view of
exclusiveness, will certainly lend force to the argument in favor of pref-
erence. This careful anatomist found that the left hemisphere is de-
veloped before the right, and that it is better nourished. Both of these
circumstances are owing to the greater supply of blood which it re-
ceives.

Undoubtedly many of the cases which have been brought forward
as militating against the doctrine of localization of the organ of speeoh
are not cases of aphasia at all, but simply instances of inability to speak,
from paralysis of the muscles concerned in speech. This is certainly
true of the greater number of Seguin's cases, and also, as Bartholow '
has stated, of those adduced by Ladame.

Again, in very many instances the post-mortem examination has not
been properly made, and lesions involving one or the other anterior lobe
have been overlooked. It is now a well-recognized fact that the cere-
bral tissue may be materially diseased, and the lesion not be detected
without microscopical examination^

Giving a very full consideration, therefore, to the facts and argu-
ments which have been urged on all sides of the question, I am con-
strained, while rejecting tlie restricted location of MM. Dax, and the
still more limited situation contended for by Broca, to believe:

1. That the organ of language is situated in both hemispheres, and
in that part which is nourished by the middle cerebral artery.

2. That while the more frequent occurrence of right hemiplegia, in
connection with aphasia, is in great part the result of the anatomical
arrangement of the arteries which favors embolism on that side, there is
strong evidence to show that the left side of the brain is more intimate-
ly connected with the faculty of speech than the right.

These views are further supported by several interesting cases, the
histories of which I now propose to relate:

Case I. — In the summer of 1857, while I was on duty, as medical
officer of the army, with a body of troops and topographical engineers^
making a road from Fort Riley to Bridger's Pass, in the Rocky Mountains,

* " On the Connection between Loss of Speech and Paralysis of the Right Side," BtrU"
ish and Foreign Medico- Chirurpical Review^ April, 1866, p. 481.

' " Aphasia and Agraphia," '* St. George's Uospital Reports," vol. ii., p. 88.
' ** On Aphasia," Journal of Psychohfficdl Medicine, etc., toL ii., p. 841, ei 9eq.

APHASIA.

191

dI occurred between two of the laborers, which resulted m one
of tbem strikiDg the other a violent blow on the head with a club,
I iojured man fell to the ground slunned, and remained in a state of
► for screral hours. Upon examining him a few minutes after the
iflair took place, I ascertained that there was no atertor and no Indica-
taoii of parmlyii^. He was unconscious and breathing quietly, with a
pobe of about 80, He had received a blow on the left temple, which,
thoagfa laying open the scalp, had not fractured the skuIL Gradually
Im regained conscioxianess so as to bo able to comprehend what was
fiuiing about him, but ho had entirely lost the memory of words, though
aoithfi faculty of articulation. Thus he was unable to speak unless the
irorfs were tirst repeated to him, and then he could do so without any
defect of articulation, provided too many words were not given to him

^ when 1 said to him in Spanish — he was a Mexican^ and could
nolipeak English^ — "Como sientes ahora ? " " How do you feel now? **
fe repeated, " Como sien. aien* sien.," and then, looking at me in ap-
pKwit despair, burst into tears. Ami this was repeated time and again
during the hour I spent with htm.

The next morning, at about seven o'clock, as he attempted to rise
bom his IkkI, be fell, and was found a few minutes afterward by the
hat^Ui attendant, lying on the ground in a state of complete coma. I
•w Urn almost immediately ; he was breathing stertorously, blowing
ootliis li|)a and cheeks at e^ch expiration, and exhibiting a general reso-
la*i»Q of all his limbs. He died at about eleven o'clock A. m. that day.

Tint afternoon I made a post-mortem examination. On removing
t^cdTETtum, the first thing that attracted my attention was an ecchy-
9imi «po£ about the size of a half -dollar-piece, involving the left ante*
iw lobe at its lateral and posterior margin. There was no extensive
vaenrliage at this point. Bat, on the opposite side, there had been a
(19^ <)^ tt^ middle tneningcal artery, and an immense extravasation
of blond wbieh had infiltrated between the lobes of the right hemisphere
"»4 wllccted in the base of the skull. My theory of the case was that
^wj hacmnrrhage from the artery had been suddenly stopped during the
^ition of primary insensibility before any considerable quantity of
Wmxl liad been effused, luid that during the night hia heart had re-
^^^t^l its power; and this, with the muscular effort he made in at-
^•otpting to get out of bed, had dislodged the eoagulum, and allowed
^*»* h»mL»rrhage to take place. At that time I attached no especial im*
P^occ to the injury of the left anterior lobe; but, since the debate in
'' iM*h Academy in 1801, I have had no doubt that to it the amne-
.^^ia was entirely due,

it frill 1m3 observed that there was no defect of articulation in this
'Stt^-, either from paralysis or incoordination, but that the difficulty was
•okly aa regarded the memory of words.

mmm

192

DI&SABES OF THE BRADf.

Case IL — J. H*, a captain of a coasting- vessel, consujtoti me
Tembcr, 1864, for a difficultj of speech with which he had been aJTect^
for several months. Upon inquiry, I ascertained that on© morning ea
he had been called from his bed upon some duty connected with
vessel; that he hud risen rather hastily and gone on deck; that wh
giving an order he suddenly became very dizzy, and fell, unconsclc
He soon regained his senses, but found that he was paralyzed on
right side, and had lost the ability to speak He soon afterward reachd
port, and remained at home for three months, during which period tl
paralysis disappeared almost entirely, and he reacquired the ability i
apeak. The aphasia was of both the amnesic and ataxic forms. He
could neither speak nor write.

He then went to sea again as a passenger to Cuba, and while in
Havana had another attack similar to the first, but without paralysis of
motion, though there was loss of sensibility on the right side. Tht,
memory for words was entirely destroyed, though he could pronou
distinctly any word he was told to say, if he did not allow too long* i
period to elapse between the direction and the response. About fou
months after his last seizure he consulted me.

At this time he could say a few words, and he employed them tal
express all his ideas, assisting himself with very energetic gesturtfljj
which, however, were rarely expressive of his thoughts. The words bal
thus constantly used were "sifi," which signified both yes and no, M\i\
** time of day," which he employed when he had any other answer tliaa
a simple affirmative or negative to give. Besides these cxju-essions, b«]
had an oath, *' Hell to pay 1 " which he ejaculated whenever he did flo^J
succeed in making himself understood, and sometimes without any sudll
exciting cause. These were the only expressions he could ongiMt«|1
but he could pronounce distinctly any word he was told to say, aud even |
as many as three short successive words. When told to x^Tite, he took
the pen, and, on my telling him to give mo his name and address, wrote.
** Time of day," and then, seeing that that was not the correct answer J
immediately followed it with " Hell to pay I " On my remarking to hiiil|
that he had given mo wrong information, he immediately wrote "sit*l
Any word, however, which I told him to write, he did without iD|
difficulty, and thus I obtained several long sentences from him*

From his brother, who came with him, I obtained the facts in
history I have mentioned. Examining his heart, I found that he
a strong systolic murmur, and was told by his brother that he had ha
fifteen years ago, a first attack of acute articular rheumatism, which had
been followed by several other attacks.

The main point of interest about this case — and it is one of those]
shaU again draw attention to — is, the occurrence of ataxic apliasia wifcl
hemiplegia as concomitants of the first attack, while the second
characterized by purely amnesic aphasia aud no paralysis.

APHASU.

193

HE in. — ^Diiring the winter of 18G8-'(30, a iimn came to my cli-
at tlie Belle^iie Hospital Medical College, who was aphasic, and
whose friencLsj his own gestures, and the few words he could speak,
ned the following histon^: Some months previously he had been
in a stone-quarry, and was struck by some piece of machinery on
left side of the head, at about the junotion of the frontal with the
iral bone* For a short time lie w^as unconscious, recovering", how-
^vithout paralysis, but with loss of the memor)" of wortls. When
e under rny obserration, he was very inteUigent, comprehended
word said to him, and made repeated and persistent efforts to talk,
lUt he could not utter a word spontaneously beyond " yes '* and " no,*'
'%hie!i he always used correctly. Thus, when I asked him wh^re he w^as
ho became much excited, gesticulated violoutly, and apparently
evcfy effort to tell me. Tho pei-spiration stood out in large drops
forehead, but no sound came from his lips. Then the following

tion took place:
iVero you bom in Prussia ? ^ " No,''
in Bavaria?'' ** No."
luxVustria?'' ** No."

Switzerland?" "Yes, yes, yes, SwitzerLind, Switzerland," at
no time laughing, and moving his hauds actively in all directions.
Id pronounce words well, but could not write,
ti)ok occasion to speak at length on the subject of aphasia, and
il AS my opinion that there had been a fracture of the internal
of the skull, and that a fragment of bone was pressing on the poa-
**nor »nd lateral part of the anterior lobe. My friend Prof. Sayre was
P'^'**f»*» and I advised him to trephine the patient, with the view of
- any depressed piece of bone, and restoring the normal func*
- . :iiat part of the brain. The operation was pei*formed a few day^
^tennid, the patient being placed under the influence of ether. The
■^^talble waa found to be fractured, and a splinter was presaiug on
^^^^bor frontal convolution. It was removed, and^ as soon as
^o» p&ticnt onierged from the aiuesthetio condition^ he spoke perfectly

This, as will be seen, was also a case of amnesic aphasia, unaccom-
pWtod by paralysis.

CAMt IV. — A- E., formerly a bookseller, consulted me in the autumn
••two for what was csonsidered by his friends to be, and what probably
^ •ftfti*mug of the brain. Before any symptom of disease appeared,
• Wl been noted for his remarkable memory, but was now exoedingly
"iqErtfttI, especially as regarded words. Thus he had forgotten his first
*ift%and ccnild not tell mc tho names of his children, nis conversation
VMoaiked by great hesitancy, from his not remembering the words he
lo 096, and there was, besides, marked difTiculty of articulation,
90im words be oould not pronounce at alL ITiere was right herai-
13

DISEASES OF THE BRAIJr.

plegia, which bad gradually been getting worse, and whichj when I
him^ was extensive eoougli to interfere materially with the movem*
of his ann and leg. The left aide was not affected, and the tongue and
face were apparently not paralyzed. He was subsequently lost at sea in
the steamer City of Boston.

This case, therefore, exhibited both the amnesic and ataxic forms of
aphasia, and was accompanied by right hemiplegia, I regard the con-
dition as being due to thrombosis, probably of the left middle cerebral
artery.

Case V.^ — W, W., aged forty-one, entered the New York State Hos-
pital for Diseases of the Nervous System, August 22, 1870, hemiplegio
on the right side, and affected with ataxic aphasia. In the month o(^^
March, 1868, as ascertained by Dr. Cross, the resident-physician of the^l
hospital, he was seized with a dull pain in the right knee, acc<)mpanied
with numbness, formication, and pricking sensations, limited to the right
foot, while general numbness of the whole side soon supervened. Those,
with loss of power, gradually extended and increased till at the end ol]
two weeks the patient was entirely hemiplegic. There was at no tini<
any loss of consciousness nor any mental aberration. On the 11th o!
May following, the patient suddenly lost the power of speech, but h
mind remained perfectly clear, anxl, thoygh he could not utter a wo]
he understoo<i well every thing that was said to him. He retnaini
nearly completely aphasic for four months, being only able during t
time to utter a few sounds, which could not be interpreted into in tell
gible words.

About September, 18G8, he began to enunciate a few wonls, at fi;
very slowly and iJidistinotly, and gradually acquired more facilr
MHien I presented him before the cki^s at the Bellevue Hospital M
cal College, in November, 18T0, although he could talk, his power of co-
ordination was very imperfect, and many words were articulated wit^h
great difficulty. Tliis trouble was chiefly manifested in regard to labials
and linguals, such words as ** truly niraly" " Peter Piper," "baker/* and
others of the kind, causing him to make repeated efforts before he could
even imperfectly pronounce them. There was no paralysis of tJ^
tongue, no deviation when it was protruded, and but \QTy slight if any
paresis of the orbicularis oris or other facial muscles. The arm and leg
on the right side were profoundly paralyzed.

In this case there was no loss of the memory for words, and no diffi-
culty in writing. It was, so- far as the aphasia was concerned, entirely
ataxic in character, anil accompanied by right hemiplegia.

My opinion was, that the sjTiiptoms were to be attributed to throm-
bosis of the left middle cerebral artery.

Cask YJ. — R, M,, aged twenty-five, noticed one day that his right
foot was unusually cold, A few days afterward he had his first attack
of hemiplegia of the right side. Suddenly, and without the least

APHASIA.

1&5

m^rmng^ except a severe vertigo, he fell, but immediately arose* ITiere
\ no loss of consciousaess, and with assistance he was able to walk to
ience,* & short distance oil. His face was drawn to the left side,
speech and memory were slightly impaired,

la February, 1869, having recovered motility, he was seized with

atkolher ftttack of right hemiplep^ia. This time he partially lost con-*

tdousQCfls, and his speech again became affected. By April, 1860,

lie waa able to resume his work as a weaver, but his ann was still weak.

Id JnJy he had another attack, %vhich was slight.

In May, 1870, he again suddenly became hemiplegic on the right

There was no loss of consciousness. The face and tongue were

liiKied* With assistance he walked home, and in a week had quite

itooTcred*

In Juiy» 1870, he had his fifth and thus far last attack. Wliile
cliopijlng wood ho was suddenly seized with a violent pain in the head,
Mowed by vertigo. He fell, but did not lose consciousness. There
wcm right hemiplegia again, difficulty of speech, and dilatation of the
fefl |mpiL For five da}^ afterward he was delirious, but finally re-
coTCfed, with loss of power in the right arm and leg, and increased
diflicdty of speech. September 1st, he was admitted to the New York
Stttu Hospital for Diseases of the Nervous System* At this time the
incdy&is had entirely disappeared; the tongue could be moved, freely
^ Any direction, and his articulation was perfect. But his memory for
'^'jrdii was greatly impaired, though facta and circumstances were re-
"« -mbered perfectly well. His speech was therefore hesitating, and if
•A^ii*! lo repeat a sentence of tliree or four words he could not do it.
Tnito he could not repeat the words ** sugar, coffee, crackers," although
lq immediately after I had finished saying them.
-.i^mination showed that the patient had hypertrophy of the hearts^
^ih lortio insufficiency/ My diagnosis waa, repeated attacks of embo-
otOiotthm left middle cerebral artery, or its branches.

tUscase was one of partial amnesio aphasia, with ataxic aphasia,
*iucii liad disappeared with the hemiplegia.

Case VII,— Mrs, S. H, W., aged thirty ^two, married. On the 26th
<*Uun*?, 18C0, about three weeks after the birth of her child, she waa
•lifcnly seized with a severe pain in the right shoulder, which extcnd-
*4ibwQ the arm. Symptoms of albuminuria, accompanied by general
"POftT, immediately ensued, and in a few weeks the dyspncea from
•fdiotbomit was alarming. Coma and a convulsion followed. Soon
ift«r the fit, which marked the height of her disease, as she was sitting
If the bed^ resting her head on her folded arms, her right side became
tOOipletely paralyzed, and she lost the ability to speak. She was not

' I Ittfv 0Qndf4U«^ the histririci of thi$ and the precetliag caae IVoni the reports of Dn
0«% bi tn^ dlalod locture oa ** PartEal Cervbral AiiJGmia/* pubtijhed tn the Jounud <^
Wdn* for JMiuary, 1871.

196 DISEASES OF THE BRAIN.

entirely clear in her mind for a week after the attack, but gradually
the dropsy disappeared, her intellect improved, and the paralysis became
less.

At the time of the seizure, the face was drawn to the right side, the
tongue deviated in the same direction, and there were strabismus and
partial ptosis and paralysis of the orbicularis palpebrarum muscle on
the right side. Motility and sensibility in the right arm and leg were,
at first, completely abolished, but at the end of ten days she was able
to move about, by holding on to a chair. During three years she con-
tinued to improve as regarded the paralysis, but for all that period did
not speak a word. In the summer of 1863 she became able to say the
word " no," and a few months later she could say " yes."

At my request, she allowed me to present her before the class of the
Bellevue Hospital Medical College, in November, 1870, on the occasion
of a clinical lecture on aphasia.

She was then, and is now, enjoying good health, with the exception
of frequent headache. Her countenance is remarkably bright and cheer-
ful, and her whole expression is exceedingly intelligent. She compre-
hends every word that is said to her, and attends to all her household
duties. Yet she is unable to utter any words but " no," " yes," and.
" dado." The latter is seldom employed, but in her vocabulary signifies
adirmation. She uses "yes "for affirmation, and "no" for negatior^,
and both for doubtful or indifferent conditions. Thus, if asked how sht^
is, she answers "Yes, yes, no, no," which means that she is tolerably
well. Sometimes she employs these words quite indiscriminately. 3Lf
asked what that is, pointing to a fan, she cannot tell, nor can sne g*^-
peat the word fan. She shows, however, that she knows, by making'
the gesture of fanning herself. She can neither read nor wri*tre,
although on one occasion she succeeded, after great difficulty, in
writing "no." Not long since she suddenly ejaculated, "I don't
know ! " and a few days ago exclaimed, " How do you do ? " but she was
not able to repeat either of these phrases, nor did she appear to ho
aware that she had said them. Her gestures are very intelligent and
expressive. The right arm and leg are weaker than on the left side^
and the sensibility is less.

There is a murmur at the apex of the heart with the first sound.

(Ophthalmoscopic examination showed the vessels of the retina of
the left eye to be much larger than those of the right.

In this case I diagnosticated embolism of the left middle cerebral
artery.

The aphasia was of both the amnesic and ataxic forms, and was ac-
companied by right hemiplegia.

Case VIII. — Mr. B. consulted me in November, 1870, for loss of the
memory of words, and fullness and pain in the head, with" occasional
vertigo. Over a year previously, while in the woods of Minnesota buy

APHASU,

107

abcFp be liad sudtlenly lost consciousness for a few moments,
*0(1 on recovering found that he had become hcmiplegio on the right
ttil<5, and httd lost the power of speech. For a short time ho could not
utter a word, but gradually tlie memory of language, and the ability to
coOniinate the muscles of speech, returned to him, and he could articu-
Ute sufficiently well to be understood. For several months, however,
his recollection of words was bad.

For Bomo time he had been under the care of Dr, Hale, of Cliicago,
t homa^opathic physician, who advised him to place himself under my
chmrge. When I first saw him, he coidd talk quite well,, but there was
iliD & hesitancy in his speech, and occasionally words were misplaced
orimscalled. Articulation was distinct, and the hemiplegia had disap-
pMVSd* There was pain, almost entirely con fined tcr the left temporal
Rgioo, There was the history of acute articular rheumatism, and there
WM lortio insufficiency.

In this case there had been at first amnesic and ataxic aphasia, with
lij^t hemiplegia. As the latter disappeared, the ability to coordinate
tkl oittscles of speech was increased, until at last articulation became
perfect, and only amnesic aphasia remained.

Ca5K IX, — H. I-, a merchant, consulted me in August, 18CD, for
hemiplegia, with inability to speak. ^Miile sitting at his desk, six
'Tp^ks previously, ho suddenly became vertiginous, and lost conscious-
fttM for a few moments. On recovering his senses, he discovered that
^ 1^11 paralyzed on the right side, and that he could not speak a word*
Hawis exceedingly anxious to make known some wish, and one of his
(hdoi brought him paper and a pencil, but he coidd not write a letter,
^alphabet was then written, but he was unable to aeleot the letters to
tjimxhe words ho wanted to use.
—^ A physician was sent for, and Mr* L was bled to the extent of six-
^^Uien ooaofd, without any favorable result, lie remained hemiplegio
^^»><1 voinpletcly aphasio for about two weeks. He then began to walk^
wdioqaired the ability to say **what,'* ** certainly," and "saw my leg
tt^" irhich ho contracted into " sawmelegoff," accentuating strongly
«• i&kbtuite syllable. These words he used without apparent intelli*
PWI, though he elcarly understood all that was said to him, and
■SgM at any joke as heartily as ever. His condition was about the
•*• when I saw him.

Re QoaUi protrude his tongue and move it actively in all directions,
•Bioottld not articulate any words but those mentioned. Thus, when I
•■bdhim to aay " table," ho said ** Certainly; " and when I said "Well,
■it it tiicn,** hv exclaimed, " Sawmelegoil* ! " at the same time, to show
*i»t Le undiTstood what I said, he went across the rt>om, and put his
Ittod on A table, uttering, at the same time, his full stock of words,
*^what,'' *' certainly,** **sawnielegoff."
I then asked him if he could write; he replied, "Certainly,'* I

108

DISEASES OF THE BRAIK.

placed paper before him, and gave liim a pen with ink^ but he was
unable to write Lis name as I requested, although he could use his
fingers for other things tolerably well, I asked him to draw a seriei i
of parallel Unes^ and he did so without dillicult j. On my insisting that
he should now make An effort to write his name, he made the attempt j
with this result:

Flo. ID.

I told him that was not his name, at which he gesticulated violeni
exclaimed, '* SawmelegofF I " and gave me one of his visiting-cards.
This gentleman continued under my eare for some time, but with no
perceptible change* He had had two attacks of acute articular rheu- h
matism, and had, when I saw him, both aortic and mitral insufficiency, S

Here, then, was right hemiplegia, with fully-developed ataxic and
amnesic aphasia. My diagnosis was, eniboHsm of the left middle cere
bral artery.

Ca8E X. — Miss C, R*, of strongly -marked hysterical diathesis, sud-
denly became a phasic while sitting at the breakfast-table. I saw h^
about two hours subsequently, when she drove to ray office with he
mother. There was no paralysis, the tongue could be moved freely in,
all directions, articulation was perfect, and she could pronounce any
word mentioned before her* The memory of words was, however,
entirely abolished.

Case XI. — Mr. S., a retired merchant, consulted me in Septembefi
1870, for. the effects of cerebral luemorrhage. He w^as hemiplegic oa
the right side, and unable to talk. His intelligence was good* He
could read, but he was not able voluntarily to pronounce a word. The
tongue was not in the least paralyzed, nor had it been, Oecasionftlly
ejaculations of various kinds would come forth. On one occasion, as
he entered my ofTice, he exclaimed — he was a German gentleman —
" Guten Morgen, mein Herr," but by no effort coidd he repeat that or
any other expression. His attempts to speak were continuous while he
was with me; and his son who came with him said he was almost
always trying to talk while he was not sleeping.

This case was, therefore, one of ataxic aphasia, and was marked by
the existence of right hemiplegia. Cerebral hjemorrhage, involving'
the corpus striatum, was the cause.

Case XII.^ — Mn L. N,, a German gentleman, came under my care
in September, 1869, for symptoms indicative of cerebral softening. He
was slightly paralyzed on the right side. His speech was affected both

APHASIA.

199

[Ij and ataxically. Soon afterward^ in consequence of maniacal
frmptonis making their appearance, I sent him, with the concurrence
ol mj friend Prof. Flint, to the Lunatic Asylum, at Flushing. He re-
jMtiird there till September of the present year, gradually failing in
1 and physical power, when, as he was no longer in a condition to
I himself or others, his fiiends, with my approval, removed hira to
their own home. At the present time he can scarcely remember a word,
ind his articulation is very defectivi?* A remarkable feature of his con-
vmation is that he calls every thing "kazza," "cat,** He appears to
fciT9 forgotten every other word.

The history of this case points to thrombosis as the probable lesion*
Caak XlII.^This was a very remarkable and instructive case, one
which I have already mentioned under the head of embolism.

The patient was a retired officer of the army, and consulted me in
llw* lutumn of 186D for paralysis, vertigo^ and slight difficulty of speak-
ing, from which he had suffered for some months. Several years pre-
riottaly he had been under the care of my friend Dr. Metcalfe, for acute
rheumatism, with cardiac complications. The history of the case
pointed \v to embolism, and, as the paralysis involved the right

fide^I i _,i i<'ated a previous attack of embolism of the left middle
ocTobnU artery.

The difficulty of speech was sHglit; there were both amnesic and
ikiio aphasia.

Under the treatment employed he improved very much in the ability
lo wtik, to use his arm, and to speak, so much so that he and his friends
ctjtisidered him better than he had been for several years. But about
■ii werks after he came under my charge he had anothi-r attack, Thia
hroe ihtt left side was paralyzed, and there was no difficulty of speech.
GtlTaaLsm was employed, as before, and he recovered sufficiently to go
to Wif hlngton City. While there he had a third attack, characterized
hj light hemiplegia and aplmsia. H© soon recovered his power of
•p<«ch, and soon afterward had a further attack, involving the left side,
iodttanttended by aphasia. He recovered under the care of Dr. Basil
^im*» of the army, and soon afterward came again to New York. A
: time after his arrival I requested ray friend Prof. Flint to see him
Icoaauhation, with the special view of having him examine his heart.
Tl^iiwas done with thoroughness, but no abnonnal sounds were de-
While in New York he had two other attacks, during both of
he was delirious; both were characterized by hemiplegia. That
[the Mi side was unaccompanied by aberrations of language; that of
k l%ht was attended with ataxic and amnesic aphasia. He forgot
^imes o£ thi* roost ortlioary things, and there were many words that
I Mold not articulate at aU. Thus, when he wanted a fan, he called
**t Urge, flat thing to make a wind with." Ho forgot my name, and
AMtld not pronounce the words beetle, general, physician, and many

200 DISEASES OF THE BRAIN.

others. I sent him to Newport greatly improved, but he had other
attacks there, and finally died in the autumn of the present year, of, I
presume, cerebral softening.

The interesting features of this case are the concurrence of hemi-
plegia and ataxic and amnesic aphasia, and the striking fact that there
was no aphasia when the paralysis involved the left side. Thus, accord-
ing to my views of the case, the patient had repeated attacks of cere-
bral embolism. When the embolus lodged in the left middle cerebral
artery, there was aphasia accompanied by right hemiplegia; when the
embolus obstructed the right middle cerebral artery, there was left
hemiplegia, but no aphasia.

Case XIV. — ^In the early part of December, 1870, J. M., a patient
of Bellevue Hospital, was, at his request, brought to my clinique at the
college. His history, as given me by Dr. Judson, showed that he had
repeated attacks of unconsciousness or semi-unconsciousness, which
were accompanied with hemiplegia. Dr. Flint had also detected a bel-
lows murmur, but it was at the apex of the heart. The patient had
suffered from several seizures of acute articular rheumatism.

Upon inquiry, I ascertained that he had had altogether eleven at-
tacks of vertigo, unconsciousness, and hemiplegia. His intelligence
was good, and he spoke tolerably well, though with hesitation and oc-
casional difficulty of articulation. His speech was much better than it
had been, and there was no well-marked hemiplegia.

As in the case last mentioned, whenever the hemiplegia had been
on the left side there was no aphasia, but when it was on the right side
there was always well-marked difficulty of speech, both amnesic and
ataxic.

Tlie only other case, similar to these last two, that I have been able
to find, is one reported by Dr. Stewart,* of a man who was admitted
into the Middlesex Hospital, suffering from left hemiplegia, without
aphasia. A week later he became affected with right hemiplegia and
loss of speech. He died, and on post-mortem examination both middle
cerebral arteries were found plugged with emboli.

Casb XV. — Captain C, an officer of the mercantile marine, was
attacked in September, 1874, with sudden loss of the power of speech,
.attended with confusion of ideas, and vertigo. He soon recovered, but
had several subsequent seizures, characterized by vertigo, impairment of
language, and slight delirium. I first saw him on the 31st of October,
and on the 28th of November he went with me to the University of
New York, where he was one of the subjects of my clinical lecture on
aphasia, delivered to the medical class. At this time, and for sevenJ
weeks previously, he had constantly used words which were without re-
lation to the things he wished to name. Thus, if he wanted his boot8|
he would ask for his top-sails, or would be apt to employ some other
» Medical 7ime$ and Gazette, July 9, 1864.

AFHASU,

201

iig^nating^ part of a sliip. In liis conversations with me he cou-

tinually exhibited tliis peculiarity. There was no want of memory lor

other parts of speech than substantives. For instance, I held up a

;e before Uim ; he at once said it was to cut with, but, whea I

liLm to name it, he called it a " boat.'* A thennometer was an

inchor,** and a watch was a " capstan," When I asked him to say

Sittional iHtdligenceVj he said " National intelligence-oflice," and, no

tttcr how often I repeated the words, he always said " Naitional intelli*

»ffice," The reason for this was very obvious; ho had frequently

Indooc&sioa to say *' intelligence-office," but had probably never before

in his Ilfo been asked to say ^^ Natiofutl LitelllfjencerJ*^ After a time,

W succeeded in acquiring the power to utter the final **t' r," but then

ht placed it in thu wrong position, and said " National intelligence-

officer," Syllable by syllable, he could speak these words correctly,

Imt they w^ere at once forgotten. This was a typical case of the am-

oesifl form of aphasia.

M&oy other cases of aphasia have come under my observation, but
it ti scarcely necessary to mention them in detail, as they present no
leaiores differing in any material point from those t^ited.

Thti views which the cases I have observed have led me to form,
kate been confirmed by my recei^it study of the subject of aphasia.
Thtm have already been given in part, but the detail of the foregoing
Uft9ne« enables me to express tlie renminder with more conftdence.

It cannot have failed to strike the reader that, in all the cases of

^Lr.i t i ^j^^ fanned a feature, the aphasia was of the ataxic form,

10 was no hemipiogia the aphasia was amnesic. In the

' 1 hvitlual was deprived of speech, because he could not co5rdi-

lu- (uuscles used in articulation, in the other because he had lost

mory of words,

liiis is a point which has not hitherto been noted. The phenomena

inriicate, I think, very clearly, the seat of the lesion, and the physiology

> parts involved.

ay matter of the lobes presides over the idea of language,
ver the memory of words. When it only is involved, there
•legia, and there is no difUculty of articulation. The trouble
- -, ^ »„(.r as regards the memory of words.

Tho oorpus striatum contains the fibres which come from the ante*
Qflroolumn of the spinal cord, and is besides connected with the hemi-
^pbifft. A lesion, therefore, of this ganglion, or other part of the
•otor timet, causes paralysis of motion on the opposite side of the
tajy, Tlie cases I have detailed show, without exception, that the
^Wirof coOrdinAtlug the muscles of speech is directly associated with
lbiilieisu|»te|giA. A lesion, therefore, followed by hemiplegia and ataxic
>pfatii| indioalea the motor tract as the seat. If amnesic aphasia is also
fnaeot, the hemisphere is likewise involved* An analysis of the caset

ao2

DISEASES OF THE BBAm.

reported by Ogle, Jackson, and some other observers, shows that the
association existed in their cases, although they have not noticed it as
of any pi lysio logical or patholog'ical bearing.

Another important feature of the foregoing cases is the constant
association of the aphasia with right hemiplegia where there was any
paralysis at all. This indicates, perhaps, only tlie more frequent occur* m
rence of embolism on the left side, but the last two eases, as well as the^
one quoted from Dr. Stewart, show that the left hemisphere is more
intimately connected with the faculty of speech than the right. In fact,
it appears to me impossible to avoid this conclusion.

Prof. Ferricr* has quite recently enunciated views relative to the
path o -physiology of aphasia^ w liich differ in several respects from those
I have just expressed. The importance of the subject, and the de-
servedly high position in cerebral physiology occupied by their author^
must be my apology for quoting them in full :

** Much has been written on the subject of aphasia, and many differ-
ences of opinion still continue to exist among those who have directed
their attention to it. It is not my intention to enter into any length-
ened examination of tlie theories which have been advanced, nor to
controvert the opinions of those who deny all localization of braio-func-
tion including a * speech-centre.' The researches of Broca, and the nu-
merous confinnations of his observations which have been put on record,
taken with the results of my expcrimcnta on monkeys, and the lower]
animals, seem to me to establish the fact of a localization of the faculty
of speech, and to explain at least the broad features of the pathology «
of aphasia, I have shown that the region which governs the move-
ments concerned in articulation h that whirh is the seat of lesion in i
aphasia. The region is symmetrically situated in both hemispherea,.!
each one possessing the power of originating coHrdinate movements of]
the lips and tongue, in a bilateral manner. Broca's convolution isf
usually described as being the posterior third of the inferior frontal I
convolution of the left hemisphere* It would be more in accordaQCe \
with tlje facts of experiments on monkeys, as well as wnth the easds
which have come under my own observation, to localize the speech-
centre in the opereitlum (Klappdeckel), which is included between the
ascending and iiorizontal limbs of t!ie fissure of S^dvius, and which im-
mediately overlaps the island of ReiL While Broca's convolutioa iBl
placed in the left hemispln^rc, the centre for bilateral coordination of j
the speech-muscles exists, as 1 have said, in both hemispheres. To thiai
bilateral action of each centre is to be ascribed the peculiarity of lo
of the faculty of speech without paralysis of the articulating musclea.
For, as regards the mere muscular action, one centre is capable of carry-
ing it on when the other has been disorganized* This contrasts in a

^ *' Pathological Blustrntions of Brain Fuoetloo/* ^* West Hidiag Luaatio Asjicim Med-
ical Eeporttj/* London, 1874, toL i?,, p* 54 »

APHASIA.

203

ngxiific&iit manner with the coincident hemiplegic paralysis of the
tzm and ocoasioaally of the leg^ which frequently exists along with the
tphasia. The centres for the moveraents of the arm and hand are in
^^006 contiguity to the centre of artieulatioo^ and hence the lesion
^Htticli causes aphasia usually involves these also* More rarely the leg
^B affected, owing to the fact that, being at a greater distance, the
^Bntxea are less often invaded by the softemng. These residts are to
W foittid when the cortex of the brain alone is ioiplieated, the ganglia
hmg intact, and furnish conclusive proof of the localization in the
btaiii*eortex of the centres for voluntary motion. These centres,
wever, have another signification, in so far as they fonn the motor
ibstrata of mind. Besides being centres for the accomplishment of
ids of volition, they form the organic centres of the memory of accom*
ibkbed acts. The centres for articulation, besides tlieir function of
ilttillg in action the complex and delicate moveraents involved in ar-
spoech, have the power of permanently recording the results of
telr functional activity. Words represent the movements of articula-
in, guided by impressions of mind, Tlie memory of words must have
in that part of the brain wliich is the centre involved in
'fSiecution, for the memory of words is nothing else than the
Vimarj of the articulating processes, which have been affected under
tb« guidance of auditory sensations. The ideas of which words are the
itxtcobtory symbols have no relation to that part of the brain where
wonls are remembered, except by associating fibres. ITae ideas, in
plij$iological language, have their organic seat in those parts of the
Wtta fpocially related to the nerves of common and special sensation,
toilliilisas are ultimately reconcilable to impressions of sense as their
W», Th«* records of these in the brain cells furnbh the material of all
thcxiglrt^ and by their various combinations and associations constitute
ilia fonatUtion of all complex conceptions. The utterance of a word,
wilb ta ftpprecitttiou of its meaning, involves the pliysiological activity
oot laeftsly of the speech-centre, but also of those parts of the brain
nUUd to the various senses concerned in the p+_^rception of the quali-
ii£t ol the object signified* Thus the mention of the word * orange'
©ot only the activity of the speech-centre, but also of the
OttEktres of color, smell, taste, form, etc., all of which are con-
^^o*ed in oiir concept of the object, TliLs is a concept of the simplest
fora, but the analysis of more complex ideas must necessarily be the
in principle,
'Uaaphaaia eonseqtient, as it usually is, on disease of the left hemi-
tb© mtnwry of words is not lost, nor is tlie person incapable of
>tin|r the meatung of words uttered in his hearing. \^liat i«
la is, as Hughlings Jackson so clearly discriminates, merely
of voluntarily using words to express ideas. As both sidea
brain are Bymmotrical, and work conjointly, the memory of worda

204

DISEASES OF THE BRAIN,

may remain in the rig'Kt hemisphere after the occurrence of lesion i
the left. Tlie explanation of the loss of the faculty of speech Is to be
attributed to the unequal preponderance of the left hemisphere in the J
inclination of voluntary actions. The left hemisphere, like tho ri^tl
side of the body, is the leading or driving side, so that lesion of the J
left side is like the loss of the right hand* It requires long educatioaj
to enable the person to accomplish, with his left hand, all the delicat^^
manipulations of which the riglit hand was capable. The leading
action of the left hemisphere may, however, be merely an accident of,
education or necessity, and there is no reason w^hy articulate spee
should not be the function of the right side. That such may be theJ
case there are pathological grounds for believing, viz., in those whcroi
aphasia has resulted from disease of the right hemisphere, and in those
rare cases where lesion of the left speech-centre has not caused the M
usual residts." ^

It is very evident, however, that the view of Dr, Hughlings Jack-
son, thus enunciated and indorsed by Dr. Ferrier, is not of unifonn
application to the phenomena of aphasia; for, though in some cases
there is no loss of the memory of words, but merely a loss of the volun-
tary power to utter them, there are many other cases in which the
patient has lost the memory of words, and has not lost the voluntary
power to articulate them* Thus, the person who speaks of his boots asd
his "top-saib,^' hus nut lost the voluntary power of saying "boots," for'
he can utter the word when asked to do so, an act which would elearij
be impossible if he had no voluntary power to say *"' boots," I have
witnessed several cases in which the patients could say any word they
were told to say, but who could scarcely articulate a syllable when not
prompted. Of these, Case III., described in tliis chapter, is a remafk-
able instance, and others will, in this connection, attract the attenticsa
of the reader. The fact appears to be, that the only cases in wbich the
voluntary power of articuhition is lost, are those which are described in
the present chapter as instances of ataxic aphasia.

So much for some of the various theories which ejost relative t^ the
localization of the organ of language and for the clinical history of
aphasia. I have not thought it necessary to discuss the view of Schroe-
der van dor Kolk,* that the faculty of articulate speech resides in the
corpora olivaria, because there is little if any physiological or patho- '
logical evidence to sustain it. Nor the hypothesis of Brown-S^quard,'
that speech is a reflex phenomenon, because there is no evidence in
support of that opinion. Neitlier have I, though much tempted, ren*
tured into the philosophy of the subject to any considerable extent*

As to the causes, the prognosis, diagnosis, morbid anatonty, and

^ " On the Minute StruL-titro and Functioim of the Fplatl Cord tad IfedoUa ObkogtU.**
**New Syilonhain Society Publicatbas/* p, 140,
* Segidu*3 " Mcraoir,*^ already quottHi.

ACUTE CEREBRAL MENmOITIS.

205

\og\% they have been sufficiontl}^ considered in the remarks made,
the treatment is of course that of the pathological condition to
wtdch it 18 due, whether this be cerebral hfemorrhagc, embolism, throm-
iftening, bjsteria, wounds, the bites of poisonous serpents, sypli-
^Other cause. One point, however, should be mentioned in this
eoone^tion, and that is that constant efforts should be made to develop
ibd uninjured speech*centre and to exercise the vocal organs, by constant
atleiapts to speak. The application of the galvanic or faradaic currents
to tbr? tongue and other muscles concerned in articulation, is a measure
of usefulness.

CHAPTER \ail.

ACimS CEEEBRAL MENIXGITIS.

Bt ftcute cerebral meningitis is understood inflammation of two
OMinhTiineft of the bndn — the pia mater and arachnoid* Some writera
BIT© made the attempt to discriminate between inflammation of the
*'wbnoid and inflammation of the pia mater, but there are no diagnostic
oiMb by which such a distinction can be made, and we find from post-
BWrtem examination that neither membrane can be inflamed without the
olh*»r jmrticipating in the morbid process. Inflammation of tlie dura
nvatnri^ never included under the term meningitis.

The ancients made no distinction between the several inflammatory
Sections of the intra-cranial organs, but comprehended them all in one
ttHewe, which they called frenzy — 'i&p'/^, the brain. Morgngni, however,
™»«d that the membranes of the brain were the parts generally
uiToIvfd^ and gave a very accurate account of the phenomena of an
•ttick of acute meningitis. Since then, Rostan, Lallemand, Andral,
l^ouilUud, and others, have added to our knowledge.

S^ptOHLS. — The symptoms of acute cerebral meningitis may be
'^idrf into three groups, arranged in chronological order: the stage of
intision; the stage of excitation, ami the stage of collapse.

1* TuK Stage of Invasion, — The most prominent initiatory symp-
Jj® ia headache, which may be difTused or conhned to a limited part of

^•^. When this latter is the case, the frontal region is more gen-
'its »Oftt; next in order of frequency is the occipital, and next the
, ••""poiaL At the same time the face is flusheil, the eyes are red and
"tt8«d^ and there is a decided elevation in the temperature of the head,
*wb ia not only felt by the patient, but may bo perceived by the hand
w tkft physiciim* Vomit big is generally present.

Aa might be expected, these symptoms are aocompanied by fever.
Tlii^ however, rarely runs higli, so far as the force or tha frequency of

206

DISEASES OF TOE BRAIK.

Bgards the heat of the skirr. It

Occasionally there is a ten*

the pulse is concerned, or

characterized by restlessness and insomnia.

dency to somnolence.

This stage may last a few days or only a few hours, or may be so
slight as not to attract attention. In general features it resembles the
prodromatic stage of cerebral congestion.

2, The Stage of Exciteme^^.*— A chill ushers in this stage, and an
increase in the intensity of several of the symptoms of the first stage
and the development of others soon take place. Tims the fever becomes
higher, the skin hotter, and tiic tcmporaturc of the body is elevated sev*
eral degrees — the thennometer rising as high as 105**, 106*, and some*
times to 107^, The pulse is frequent — rising to I'^O, or even 160 — quick
and hard, and the face becomes redder than in the first stage^ The pain
in the head augments in violence, an^ is increased by pressure on the
scalp, or even the slightest movement.

The eyes are bright, the pupils contracted and painfully sensitive to
light* The hearing becomes morbidly acute, loud noises cause great
agony, and even slight sounds are unbearable. The general sensibility
of the body is increased, and hence the patient is rendered uncomfort-
able by the contact of the bedclothes with the skin. Delirium is gen-
erally present from the first, and is often of furious character. Hallu-
cinations of sight and hearing are almost constant, and the irrationality
of the ideas is marked by the incolierence of the speech. The patient
when awake is coiitmually talking, gesticulates violently, and weep«
and laughs alternately over imaginary evils* It is sometinies necessary
to use restraint to prevent him injuring himself or others, and the
attendants should always be prepared for any emergency of the kind.
As the disease advances, the delirium becomes more subdued, and the
patient may exhibit some evidences of sanity.

Even when there is no delirium, as occasionally happens, the in£ti*
ence of the morbid action over the mind is shown in the irritability of
the patient, and the cliange wiuch he undergoes in character and dis-
position.

Convulsions rarely occur in adults, but motility generally is never-
theless disordered. The limbs are in almost continual action, as are
likewise the jaw and the eyelids, Twitchings of the facial and other
muscles, such as those of the forearm, are usually well marked^ and
occasionally there are irregular movements of the eyeballs. Convul-
sions, when they occur, may bo either clonic, or tonic, or both. Thus
there may be a gradually-increasing rigidity of some muscles, followed
by relaxation and disordered movements. Sometimes there is opis-
thotonos as well marked as in some cases of tetanus. Hemiplegia or
paraplegia may occur, but are infrequent complications, I have seen
two cases in which one lateral half of the body was paralyzed during
the whole course of the disease.

•^ ContmcHons of the limbs sometimes take place, and may be confined
KOiie side or a single limb. In this case the forearm is usually strongly
flexed on the ann.

The muscles of offj^anic life participate, and the bowels are obsti-
nately con«rtipated. There may be difficulty of awallowiug', from spaam
if the pharynx, and irre^larity of breathing, from implication of the
M^tmtory nmsclas.

Tbe ino?tt characteristic symptom of this stage is, however, the obsti-
Bile and violent cephalalgia, of which mention has already been made,
md yet there are cases in which it is entirely absent from first to last.
Serecml such instances have been under my own charge, and post-mor»
t*^ "uition has verified the existence of thi? evidences of menin-

gi 1^ stage lasts from a few days to two wrecks.

3. Thb Stage of Collaj»se.^ — ^The beginning of this stage is marked
by the occurrence of somnolence, "which often shows a tendency to pass
inloooma} and by a subsidence of the delirium and muscular agitation.
Untie are times, however, during which the stupor remits in profundity,
'tod tiie patient appears to be somewhat conscious of his condition, but
these {>onods only occur in the first part of the third stage. Ere long
tk coma becomes constant*

Pmlysis then supervenes, and is first manifested in the ocular or
haal muscles. Thus from paralysis of one of the muscles of the eye-
bill >tr»bismu$ «^n[?uos, or the upper eyelid may drop from paralysis of
thi Wvfttor palpebni* superioris. The pupils dilate and become insensi-
h\t to light, and the mouth is drawn to one side from implication of the
nnwles of the face. Before long the contractions of the limbs relax,
*Jwl ptrilysia takes place. The sphincters of the bladder and rectum
•^•o \om their power, and the urine and fa?ccs escape involuntarily,
Tlwpol(«! becomes slow and irregular, but the temperature, as Jaccoud
htttliawn, Eod as I have lately verified in several instances, does not
M. Some authors regard this reduction in the frequency of the pulso
^2» the heat of the body remains high, as pathognomonic. The in-
ttttibtlity becoiDefl more and more profound, and the patient dies in a
•Wtof coma, sometimes from asphyxia produced by paralysis of the
•'ipiritory muscles, but generally from the gradual engorgement of the
"■Qpi ftnd with a bodily temperature as high as at any other period of
tkdiseaie.

Such is the ordinary course of an attack of simple acute cerebral
"••^ujgitia oocufring in a young and healthy person. Though it is cer-
^^f IfUiff^ as post-mortem examinations have shown, that the mor-
W pixxess may be general or limited to the convex or basilar surface
^ A« bndn, or to the ventricular lining, yet during life the distinction
**6il0t bo made, mainly for reasons which w^ll be given under the head
^'ftthology. But there are modifications often met with which require
^BCuidmtioa. CH these, epidemic cerebro-spinal meningitis, though

208

DISEASES OF TOE BRAIN,

scarcely to be considered a disease of the nervous system, and tuberca
lar meningitis, will be discussed under otLer heads, but the differences
due to acute rheumatism and old age may very properly be noticed
in the present coniieetion.

lillEUMATIC MEXtS^GmS*

Under the name of cerebral rheumatism, several very different affeo-
tions of the brain supervening during the course of acute articular
rlieumatism have been embmced. The relation of rheumatism to such
secondary diseases has long been recognized, but very gretit confiisioii
has existed in regard to the exact nature of the morbid processes set
up in the brain and its membranes. That meningitis may, however, be
one of these conditions, appears to be quite cei-tain. Gintrac* has col-
lected twenty-one cases of cerebral meningitis the result of rheumatism,
or at least occurring in conjunction with that disease, the existence of
which was established by post-mortem examination. Oulie* con-
tributes four others, and many more are to be found in medical treatises
and periodicals.

Although I have witnessed a number of cases of what in fonxier
editions of this work was designated cerebral rheumatism^ I have only
had one case in which the existence of meningitis as a consequence of
rheumatism was demonstrated by post-mortem examination.

The membranes of the bi^ain are most liable to be affected daring
the latter stage of an attack of acute rheumatism, but there seems to be
no doubt that the cerebral clisease in question may supervene at any
time during the coui'se of the primary disease, and that it sometimes
has all the appearance of being a true metastasis. The symptoms which
indicate the supervention of cerebral meningitis are delirium, convul-
sions, or more frequently choreiform movements in the limbs, tremor,
especially about the lips and muscles of the face, paralysis in various
parts of the body, and stupor, Piiin and vomiting, which are such con-
stant features of ordinary meningitis, are rarely present in the rheu-
matic form of the aiTection. The bodily temperature is not elevated
more than three or four degrees above the nonnal standard. Toward
the last, coma, if already present, becomes more profound, or if not,
makes its appearance, and death ordinarily ensues. Occasionally, how*
erer, recovery takes place,'

1 Op, eii,^ tome ilL, p. 77.

* ** Du rbeumatLBmo c6r6brale." Thfise de PariJ^j 1868.

* In a very vultiablo memoir oa " Cerebral Rhtumfttism,*' jiist published, Prot Da
Costa ^ hua given the details of twelve cases in which cerebral feviijptoiijs siiperrLTied duf*
log the course of arlieular rheunmti^iu. Dr. Da Costii eicpreases the opinion ihdt all elides
of what Is called cerebral rbeuomtisin arc do( charncteriiieii by tlie prestpnce of mciiiii^tia,
and the results of tlie {^ost-mortem cxamiQations which he obtained from his cmB€ft, te^

ACUTE CEREBRAL BfENINOITIS.

2UU

SENILE MENIXfilTIS,

In old persons, the symptoms of acute iDeuingitia are rarely so pro-
as in individuals of middle age. The affection comes on more
ily, and may have made considerable progress before its existence
ipecteiL There is little or no pain, no fever, and no gastric or in-
tettitud derangement. The mental symptoms are very similar to those
to softeninfj^. The patient has imperfect articulation, his memory
ipairtsl, and he does things which show that he isnot in his right
ifiind. Tlie deiirium is of the low muttering kind, and there is a ten-
to coma even in the first stage* There is a more or less general
in all the limbs, and subsultus is commonly present. Death is
OBtlly due to pulmonary engorgement.

CEUfldS* — Among the predisposing causes of acute cerebral menin-
gHbySge is first to be considered. Gu6rsant * asserts that the period of
lite between siatteen and fody-live is that during which acute menin-
gitii is most liable to occur, not including children, who are far more
pwoe to the disease than adults. Rilliet and Barthez' have, however,
ibown that yery young infants are not so subject to simple acute menin-
gitii nj children of from five to eleven years of age. The very oppo*
ntp opinioa is expressed by Drs, Meigs and Pepper.*

Thirteen cases of acute simple meningitis have come under my ob-
Munition, Of these, all were be twee a the ages of thirty and forty-

Mon are more subject to it than women. Of my cases, ten were
wtlcB and three females. Parent*Duchatelet and Martinet,* however,
think womt*n are more predisposed to the affection than men.

Temperature, either very high or very low, predisposes to acute
tw^tiiugitis* Eight of the cases under my care occurred in summer and
fin ia winter.

Certain firofessions and habitudes ajipear to favor the occurrence
of IIh^ disease. Among the former are itU those which require the head

^Vrnpport tills view. But in Cime L — ii very ehAfjicterisUc in^Uuce — the bmia wm
iM cita»itic4 ; C«ac Y. recovered ; in Cti^e VL the brain wu not examined ; la Oiiitt
niL, Abo 1 m«rked cue, in which there were flushing of the fiiee, ooeasiooal spasmodic
^Vticdiiu of ih« f&cUl niitscles, contractod piipik, uniltilit^jrv motions of the body, nnd
^^of thi.« vTn», an examination was rcfusml ; in Ca^se IX., in which there were montAl
VKpteitia, fad&l paralyjii*^ ptosis, and hemipiegia, the patient reeoverrd ; in Case XJ. ns
«w*7look |tlac«, as it did aUo in Case XIT^ *o that in only six were there poat-mortcm
I liilmtiMti <if the enci^pliaioR.

I^.^Oo«lA doM not doubl tlie existence of rheuroatic meningitis, but he cont(aid\
Mil ftbk «uecc«ft6illr, that all eases of cerebral disorder, originating during the course
i^stiaaW rlieamatianif are not eases of monlngttid, and tliat in some cas«a there mt9
\f oo abnomiai post-mortem appearances.
» Xil **ilMn^ie,'* to ** Dictionnaire de M^declnc," PaHs, 1830.
* "Trmili Im nuUadies de:^ enfantj;/' Paris, 185a.
•• A Practical Tnsitise on the Diseaseii of Children," Pliiladelphia, 1870, p. 4ML
r'RcvlicTehes »tir rinflaaimation dc raraehnoide,'* Paris, 1821*

210 DISEASES OF THE BRATN.

to be exposed to strong and direct heat; among the latter are excesaive
intellectual exertion, and abuse of alcoholic liquors. Tertiary sjphilisi
gout, and rheumatism, are likewise predisponents.

Larrey ' states that in the retreat of the French army from Russia,
the soldiers, who had endured the most terrible sufferings from hunger
and cold, were attacked, on their arrival in KOnigsberg, where they had
ample food and warm quarters, with cerebral meningitis, which in gen-
eral proved fatal. This result was probably due to the operation of
many causes besides prolonged exposure to a low temperature, among
which the sudden removal of the mental tension maintained by the
exigencies of the situation in which the army was placed, was not the
least.

Of exciting causes, injuries of the head from falls or blows of differ^
ent kinds stand first. Next is exposure to the direct rays of the sun,
or other source of great heat, and then recession of an exanthematouB
affection, such as scarlatina, measles, or erysipelas, and the irritation of
dentition, or intestinal worms.

Acute cerebral meningitis sometimes prevails epidemically. Such
was the case with the series of instances which came under Larrey*8
observation, and othc)*s have been noted.

Diagnosis. — Acute meningitis may be confounded with partial or
circumscribed encephalitis, but the distinction is made by considering
that in the latter the headache is less severe, the deliriimi less marked,
and the convulsions and contractions weaker. Moreover, the febrile
excitement is much greater in acute meningitis than in partial enceph-
alitis, and the whole disease more pronounced.

The meningitis of the aged bears a considerable degree of resem-
blance to cerebral softening; but the fact that the first-named affection
is more rapid in its progress, and is not preceded by symptoms due to
other morbid conditions, will generally enable the practitioner to make
a correct diagnosis. •

From delirium tremens it may be distinguished by the history of
the case, by the greater tendency to insomnia exhibited in alcoholism,
and by the general character of the delirium. The febrile excitement
of acute meningitis, the pain in the head, the heat of the skin, the ab-
sence of clammy perspiration, and the increased temperature, as shown
by the thermometer, are conclusive diagnostic marks.

From typhoid fever meningitis is diagnosticated by the existence
in the former of meteorism, abdominal tenderness, and petechise, by
the facts that the headache and febrile excitement are less, and that
diarrhoea is present and vomiting is not.

Prognosis. — This is always grave. Occasionally death takes plaoe
in a very few hours, and generally before the tenth day. When the
disease is prolonged beyond this latter period, the prognosis becomes

' '' M^moircs de chirargie militaire et campagncs,** Paris, 1817, tome ir., p. 189.

AOTTE CEREBRAL MEKINGITIS.

211

favorable. The occurrence of strabismus or other paralytic affec*
^oiii lessens the hope of a favorable termination. Prof. Flint, however,
hfti ciUsi two cases occurring in the hospital practice of himself and
Dt, Hiomas, in which there were strabismus, hemiplegia, and coma^
both of which recoveroct He also cites another case jo which there was
ftnbismus, and in which recovery took place. Hiccough is an unf avor-
thlr event.

Of i\w thirteen cases observed by myself, eleven died. Inn II of these
(ltd cases there was strabismus. In the two cases which recovered
Skere was no squinting. The deaths in the fatal cases all occurred be-
the tenth day^ and two took place before the end of the third day.
Morbid Anatomy. — If death occurs during the second stage of the
', the most marked appearance found in the membranes is red-
Mas from increased hypenemia. If, however, it is delayed till the third
rtige, thickening and opacity of the membranes and atlhesions to each
otJwT^ and of the pia mater to the brain, and effusion of serum, are the
prominent features. In a caso in which I made a post-mortem exami-
Ottion in the summer of 1870, and which was caused by the great heat
fli tbe season, there was an extensive collection of bloody serum in the
•wity of the arachnoid, and the pia mater was so adherent as to bring
wMi it a layer of the gray matter of the brain as it was stripped off,

Tlie fluid may consist solely of pus, or this may be mingled with
•Wa in all proportions. The pus, with the fibrine of the exuded serum,
Ami forms thin plates of membranifonn texture, which are scattere<l
o^tfT the surface of the inflamed region or may entirely cover it, and
^liich arc of the nature of false membranes.

If rli^ath has taken place late in the course of the disease, evidences
*'^ ation of the cerebral substance will generally be discerned,

1' ,, ,ot in the gray matter becoming of a pinkish color, and the

^tnlf, when cut, showing numerous puneta vasculosa* The ventricles
^' ' hi any considerable amount of fluid, and are often entirely

^i' * latter was the case in the instance above mentioned.

Pitlkology. — ^The symptoms of the first and second stages are due
to 6)Qgestton ; those of the third mainly to effusion and consequent

An important question connected with the pathology relates to the
memunation, from the symptoms, what part of the brain is the seat
« th« lesson. The upper convex portion of the hemispheres is inti-
o**dy related to the purely intellectual functions of the brain, w*hile
*^ under surface, or base, is connected with the motility of various
putinf tbe body. Thus, if the inflammation bo strictly limited to the
«mT^- -' f the brain, the predominant symptoms are those in-

lality, and conserpiently there is delirium, marked by
^afi<4»t«noo of ideas and irrationality of language. If, on the contrary,
tftibtt^ if til.* brain alone is affcctecl, the chief manifestations of dis-

212 DISEASES OF THE BRAIN.

ease arc seen in the muscular system, and there are contractionBy
spasms, convulsions, and paralysis. When the morbid action extends
to both regions, there is a combination of these phenomena.

But, as Jaccoud ^ states, there are some stubborn facts which stand
in the way of the unreserved acceptance of the law laid down, for it
occasionally happens that the symptoms are not in direct relation with
the seat of the lesion. Thus, in the case the post-mortem examination
of which I have referred to, there had been spasms and paralysis, yet
the convex surface of the right hemisphere was alone involved, and that
to an extent not exceeding a third the size of the hand. Jaccoud ex-
plains such cases by attributing to the cerebral symptoms a double
origin; one set being due directly to the part affecte'd, the other result-
ing from secondary reflex excitation.

But a better explanation is to be found in the experiments of Fritsch
and Hitzig,' and of Ferrier,* by which it is shown that there are distinct
centres of muscular motion situated in the cortical substance of the
brain, and that hence when this is irritated, as in the case referred to,
by the occurrence of inflammation, spasms will be initiated in those
muscles which are in direct relation with the centre implicated. It
therefore is not necessary to frame an hypothesis to account for occur-
rences which are readily explained by facts.

Another fact should also be taken into consideration. In acute
cerebral meningitis there is very frequently a large effusion of secum or
an extensive formation of pus. If either be collected on the upper con-
vex surface of either hemisphere, the pressure exerted through the in-
tervening brain -substance upon the motor tract at the base miist pro-
duce more or less derangement of motility on the opposite side of the
body.

Guyot,* who has given very careful study to the localization of the
lesion from a consideration of the symptoms, declares that it is possible
to define the seat very accurately, but his manner of looking at the sub-
ject places it in altogether a different, position from that which Jaccoud
gives it, and which is not inconsistent with the investigations of Fritsch
and Hitzig, And of Ferrier. Thus, tracing the fibres of the motor tract
through the white substance to the convex surface of the hemispheresi
he associates lesion of this region, not only with disturbances of idea-
tion, but with derangement of motor functions. In this view he is
supported by the experience of MM. Parent-Duchatelet and Martinet,*

> Op, cU., p. 212.

* " Ueber die clectrwchc Erregbarkeit dea Gehiras." Archivfur Anatomie und Pkifd'
ologie^ Ton Du BoU-Reymond und Reichert, 1870, p. 800, et seq.

' " Experimental Researches in Cerebral Physiology and Pathology," " West Ridiiig
Lunatic Asylum Medical Reports," vol. iil, 1878, p. 80.

* " Du rapport des symptoms arec les lesions dans la m^ningite." Thdsc de Paris,
1869. • Op, rit

ACUTE CEREBRAL MBKIKGITIS.

213

that in • igbt subjects who had exhibited hetniplegia, or the
[wiing' of paralysis on one side of the body, they had discovered, on
post'mori^m examiQatioii, effusiou on the conveidty of the opposite

When, however, the lesion b limited to the base, the functions
ol the hemi«phexes will not be affected, except upon the principle of
fefles irritation, or of the transmission of pressure. It is evident, bow-
efer, that further researches, founded upon post-mortem examinations,
im neoessary to the satisfactory solution of the interesting questions

Tnatment — To afford any chance of a favorable residt, the treat-

. abould bo energetic from the first.
General blotidletting may be practised with advantage in subjects of
pod constitution and of the middle period of life. As many as twelve
or lixteeQ ounces may be taken from the arm if the pulse Is hard, the
e^ibalalgi& intense, or the delirium furious. Leeches applied behind
ths ctn Of to tlie inside of the nostrils are more genemlly of advantage.
IkAine may be said of cups to the nucha.

The hair should be cut off short, and ice kept constantly applied to
Atimlp during the first and second stages. It is better than the cotd
pfor the reason that it is almost impossible to eonliime ihe latter
ot intennbsions, during which the head again becomes hot. Com-
pMe$ wrung out of cold water will not answer; they soon get heated,
iodict OS poultices. Irrigation, by a small stream of ice^water falliog
hom a V easel placed above the head of the patient, is a useful means of
ifftring oold, but is often inconvenient.

The? experiments of Dn Benham * appear to show that cold applied
tollic liCftfl has no material effect in reducing the intra-cranial tempera-
tui«,Of in lessening the amount of blood flowing to the brain. But it
wu*t l>e borne in mind that, though cold applied to the scalp may not
n*te«? the normal intra-cranial temperature, it may exercise a very
*liiei«at bifluence over temperature which is abnormally high, and tliat
fcii espoKments with Lud wig's Strohm-uhr were but three in number,
tfcll the cold waa only applied for tliirty minutes, and that it is quite
'Mblfid if ihe Strohm-uhr affords the best means, under the circum-
itoeei, for determining the quantity of blood flowing to the brain.
Uietiial experience, we find that the sedative influence of cold to the
mi ii M well-establbhed a fact as any other in therapeutics, and,
•"Ilk it may fail, as every other remedy does some time or other, to
F'^^ooe ttn expected effect, that fact should be no reason against our
copkyineiii of it in cases in which it appears to be indicated. In acute
*inili^ afbeniugitiB, I have repeatedly seen the violence of the symp-
'^■B mkigftted by the agent in question, but, in order to obtain this

Vdu« of Cold to the Dead,'* '' W«et Riding Lunatic Aayla
, 1674, p. 151

214 DISEASES OF THE 6RAIN.

result, it should be kept persistently applied in the forms above men-
tioned.

Purgatives are generally advantageous and should be effective.
Nothing is better than eroton-oil, although calomel and podophjUin,
grs. X with grs. ij, make a good combination for the purpose.

My experience has satisfied me of the good effects of mercurializa-
tion. I have administered calomel in doses of a grain every two hours
until the breath became fetid, and I am sure the effect has been bene-
ficial.

The iodide of potassium is well spoken of by Dr. Flint,' who says he
has witnessed the good effects of the drug in several cases. Dr. F. R.
Lyman ' has reported two cases in which it formed a prominent feature
of the treatment, and in* which recovery took place.

Within late years in the few cases of acute cerebral meningitis that
have been imder my charge, I have found the greatest benefit from the
bromide of potassium, and the three cases that recovered were instances
in which it was administered in large doses. The theory upon which its
employment is based has already been fully considered in the chapter on
cerebral congestion. It should be administered in doses of at least thirty
grains three or four times a day, from the very beginning of the affec-
tion to the end of the second stage or the appearance of coma, should
this symptom supervene.

The head should be kept well elevated, the chamber cool, and well
ventilated, the light in a great measure excluded, and the utmost quiet
enjoined.

The food, without being stimulating, should be nutritious. Nothing
is superior to strong beef-tea, made either from fresh beef or from some
one of the extracts in the market.

In the third stage the treatment should be almost the reverse of that
indicated as proper for the first and second stages. The mercury, iodide
of potassium, bromide of potassium, ice to the head, and purgatives
should be omitted, and attention should be given to the maintenance
of the strength. To this end brandy, whbkey, or other alcoholio
liquor, should be administered in such quantities as the occasion seems
to require. It often happens in this stage that the delirium and exces-
sive motility return. It must be remembered that this is not from any
renewal of morbid processes within the cranium, but is entirely due to
debility. At the moment of writing this, a young lady of this city is
under my charge for acute cerebral meningitis, whom I did not see tiU
the third stage was well advanced, and who for several days previously
had exhibited a return of the delirium, for which depletive measores
and hydrate of chloral had been employed. The free administration of
brandy, champagne, and beef -tea, soon dissipated the symptoms of re-
lapse, and she bids fair to recover.

* Op. cit., p. 601. * « Ajnerican Medical TiiiMt, 1862, p. 8S4.

CmONIO CEKEBRAL MEKIKGITIS.

215

Blisters may be used in this stage with advantage. They arc
It Applied between the shoulders, and should be six or eight inoUea

In the rheumatic form of the disease little special treatment is necea-
•Mjr* It ia, perhaps, advisable to endeavor, by means of blisters or
otlier revulsives, to bring back the disease to the joints*

In tile acute meningitis of the aged, active depletive treatment is not
•o giiiieimUj admiasible, and if apparently indicated should be carried
out caatiously. It may even be proper to treat some cases with atimu-
Imts from the very first.

CHAPTER

CESOyJC CSREBRAL MKifiyGma.

AttQOCGa it is scarcely possible, for reasons given in the preceding
fhipler, to determine from the symptoms the exact seat of the morbid
piooeas in an attack of acute cerebral meningitis, we are often able, in
ibe chronic form of the disease, to make the differential diagnosis with
vttfident accuracy, I shall therefore consider the affection according to
ita loo&iion under tlie heads of Chronic Verticalar Meningitis, and
Qirottic Basilar Meningitis, the terms being applied respectively to
cbmaic inflammation of the membranes of the superior surface or vertex
oCtlw brairi^ and chronic inllammation of the membranes of the inferior
wrfae© or b&se of the braiiL

L— CHUOXIC VKKTICAULB MEXINOmS.

TMi disease may be the consequence of an attack of acute cerebral
nualsigitift, or may originate without being thus preceded* The latter
AtlieiiatiAl mode of development.

Synptoms* — The symptoms of chronic verticalar meningitis are in

•s^^ respects similar to those of general paralysis, an affection which

' fully described as one of the forms of insanity; and they also

'r ** ii-n evolved during the course of softening, limited to the

T I of the brain.
iiong the physical symptoms headache occupies a prominent posi-
iiid is tisually the first evidence of cerebral disease which attracts
**» ittenlion of the patient. The pain is generally felt in the fore*
^*^ in ono or both eyes, or at the vertex, and is aggravated by men-
W exertion, by the mere act of reading or fixing the attention, by mus-
*^ efforti or by ii dt*pendent position of the head. It is not usually
••ty iatense^ but is characterized by persistency. There are frequent
ttt&cki of vertigo. Somnolency is generally present, and there are

216 DISEASES OF THE BRAIN.

tromblingy defective articulation, weakness of the limbs, spasms of par-
ticular muscles or groups of muscles, paralysis of the bladder or of the
sphincters of the bladder and rectum, producing involuntary discharges
of urine and faeces, weakness of the memory, especially as regards
words, and a general enfeeblement of the mental faculties. Occa-
sionally there are epileptic convulsions.

Paralysis of the whole of one side of the body may ensue, or the
loss of power may be confined to a single limb, or to a group of mus-
cles. Anaesthesia may be present, either general or local, or there may
be neuralgic pains in various parts of the body, sometimes of a very
persistent character. The ocular muscles are not often implicated,
either by spasm or paralysis; and the special senses, except that of gen-
eral sensibility, are not usually impaired. Convulsions of an epilepti-
form character are not uncommon.

Unless the cortical substance of the brain participates in the morbid
action there is not ordinarily marked mental. aberration, although there
is a general failure of mental power. Under the name of *' general
paralysis," * and subsequently of " chronic, diffused periencephalitis,* "
Calmeil described a disease which is now well known, and in which the
cortical portion of the upper part of the cerebrum is in a condition of
chronic inflammation, the membranes of the region being also involved.
But the. peculiarities of general paralysis are so well marked as to ne-
cessitate separate description.

The ophthalmoscope does not, in this affection, generally reveal any
very notable changes in the fundus of the eyes. Occasionally, where
there is reason to suspect its existence, there is ischsemia papillae^ and
still more rarely neuro-retinitis. As Dr. Allbutt * has remarked, the
optic nerves in drunkards affected with meningitis of the convex surface
of the brain " arc often degenerated, and the vessels injected, but these
effects do not seem to be due to any meningitic process." When,
however, the meningitis is complicated with inflammation of the cortical
substance of the brain, neuro-retinitis is a frequent accompaniment.

The general health participates more or less in the disturbance.
The stomach is irritable, and "vomiting is frequent, the bowels are
usually obstinately constipated, and the urine is scanty and high-
colored, often containing oxalate of lime 'and an excessive amount of
uric acid.

As the disease advances, the mental and physical symptoms become
more and more pronounced. The mind is weaker, delirium is not in-
frequent, convulsions occur oftener, and the paralysis extends and be-
comes more profound. Blindness from pressure upon the optic nerves

» "De la paralys6e consider^e chcz les ali©n6s," Paris, 1826,
' "■ Trait6 des maladies inflammatoires du cerveau," Paris, 1859.
* " On the Use of the Ophthalmoscope in Diseases of the Nervous System/* etc, Lon-
don and New York, 1871, p. 108.

CHEONIC CEREBRAL itENINGITIS.

217

Jt, A state of continued coma now supervenes, during which
mi expires, or death takes place in convulsions,
TIjc duration o£ the disease varies from two or three months to one
or© jears.

interesting case of mening-itis affecting the membranes at the
cwiTexity of the brain, is that of the eminent Swiss ^avcmt De Saussuxe,
i«kte<l bv Dn Odier.*

For m&ny years M. de Saussare had been accustomed to great bodily
laiigne^ and to various degrees of atmospheric pressure, encountered
in the mauy ascents of mountains ho had made. He had been subject
(a aa aggravated form of dyspepsia, and to repeated large losses of
Uood Irom haemorrhoids.

At the end of the year 1T93, after having lost his fortune, and ex-
perienced a good deal of mental disturbance from the unsettled condi-
tbiiof the national aflfairs, he was suddenly seized with vertigo, which
••» followed by distinct sense of numbness in the left arm and cheek.
Thft rertigo did not last long, but nothing could relieve the feeUng of
or torpor. Blisters, purgatives, tonics, and anti-spasmodics,
employed in vain. The affection of the arm seemed to be seated en-
inlf in the sentient nerves, for the patient retained his strength, could
pirtoim all kinds of movements, but could not distinguish easily what
W WIS touching. It seemed to him a» if sand were interposed between
fcb fingen and the bodies with which he brought them in contact,
Tift wimtion experienced was rather painful than otherwise, so that
!• wi* indisposed to use his hands unless they w^ero protected with
^Ofoa A similar feeling existed in tlve check and mouth on the same
iidfe, which| on passing his hand over his face, formed, in the most un-
phutai manner, a well-marked line of demarkation between the right
tM hft tide. In other respects he was well; his general health w^as
not impaired, and lie retained for a long time his presence of mind and
iht fadoess of his intellectual powers. Many months were passed in
this ttilc, during which a great variety of remedies wore tried, such as
cold ixid warm bathing, electricity, arnica, valerian, blisters, embroca^
tioni, trtifieial and natural thermal waters, change of regimen, travel*
uij, etc., hut all in vain, The disease became worse and worse; always,
wvfvcfj by starts, the attacks being more or less violent and complete,
Qo* of the most violent was occasioned suddenly at Bourbon, by a
•fcot«f«b«th employed too warm. The attack produced by it was so
Mttplete that the whole of the left side, from the leg to the tongue, waa
<Act«d. Hia articulation became by degrees indistinct and unintelli-
i^Bv His legs, especially the left, became weaker, and his gait was
it||{gcTOg, and ho found it ahnost impossible to maintain his equiHb-
ftnm and to diteot his steps as he wanted. He experienced peculiar

> ^ An Aeeowil of tbe UlaMi oad Death of H. B. de Saussure, Uta Frofciiaor of Phi-
v Al Odief A,^ SimbtirffK JMkW and Surfficai /aanta^ vol IL, I80d, p. Zn.

218 DISEASES OF THE BRAIX.

difficulty in passing through doors, even when they were wide open,
and no descent or ascent to make. As he approached a door he bal-
anced himself, and quickened his motion as if he had to make a dan-
gerous leap or a bad step to get over; when it was done he recovered
his equilibrium, crossed the room, but had the same trouble in order
to get to another apartment. Day by day the disease advanced; the
intellectual faculties became perceptibly weaker; incontinence of urine
supervened. The evening before his death he seemed to enjoy his sup-
per, but was restless during the night; toward morning his head leaned
to one side, he breathed with more difficulty than usual, and expired
without agony.

On opening the body thirty-two hours after death, the dura mater
was found adherent to the cranium, particularly along the longitudinal
sinus, but that deviation from the natural condition was not considered
of importance, it being often met with unassociated with intra-cranial
disease. Between the pia mater and the arachnoid there was found
a considerable effusion of a bluish gelatinous substance. In various
places there were circular spots of a gray yellowish color about two or
three lines in diameter. These seemed as though they penetrated into
the membranes, though susceptible of being detached from them like
small separate spheres surrounded by a little circular margin of a dark-
red color. At first sight these spots were taken for hydatids, but closer
examination showed that the red margin was a blood-vessel connected
with other vessels, and convoluted in the. form of circles. There were
no separate pouches or solutions of continuity in the membranes, only
they were more transparent in those places than in others. The seros-
ity underneath communicated freely with that which was diffused over
all the surface of the brain, both having the same color and qualities.
On opening the membranes the serous effusion ran off like water. The
effusion existed not only over the surface of the cerebrum, but also
over that of the cerebellum. The ventricles also were distended with a
similar fluid. The examination of the brain presented nothing more of
importance except that it was flattened on the surface and deeply
furrowed by arteries. The total duration of the diseas6 was five yean,
although the beginning may have been anterior to the apparent time
of origination, as it was stated that Prof, de Saussure, long before his
death, had often mistaken one word for another in conversation, and
was so unconscious of his error as to get angry when not understood*

Dr. Odier attributed the death of the patient to the effusion of a
large quantity of serum into the ventricles and between the membranes
of the brain. That this effusion resulted from chronic meningitis is
scarcely a matter of doubt.

Gintraf * cites the following case: " A young man sixteen years old,

* Op. cit, tome ii., p. 626. Quoted from Bruce, ** Medioo-Chimrgical TranMctkmBi''
London, 1818, vol U., p. 280.

CHRONIC CEREBRAL MENLVGITia

219

^ was attacked in December with feebleness of sight, strubismu5>
dilfttAtioa of the pupils, dipio|na, and headache ; pulse natural, coasti-
ptiioi^ opistaads; convulsions, with foaming at the mouth; coma and
•trrtor* which were relieved hy bleeding from tho temporal artery, but
which returned twenty-four hours later. Delirium supervened, charac*
loijsed by violent langxiage, and attempts to strike and bite those
Ifoimd him ; pulse frequent* The wound in the artery being reopened,
ivpeated losses of blood occurred, and the convulsions returned. Sight
weakeDed, ideas confused, appetite voracious, general debility, but
|kDwer of walking, of comprehension, and of speech, remained. Then
vomnolency, attended with spasmodic movements of the muscles, es-
pecially of those of the face, appeared. The face was red and swollen,
(Specially on the left side. Death occurred in violent con%ndsion9 two
months after the beginning of the disease.

**The cerebral blood*vessels were found to be very much injected.
Ik the left anterior lobe there was a slight effusion of blood; a little
•emm in the vejitriclesj substance of the brain firm; numerous puru-
lent sjKjt* along the line of superior longitudinal sinus.''

NL Casiinir Broussals * submitted to the Academic de M^ecine a
pilhological specimen with the lustory, of which 1 give the main
fuiata:

Ii0»eray, a mptur pompier ^ twenty-two years old, entered the hos-
piul Val-de-Grace August 1, 1840. Six days previously he bad been
UUcked with headache and slight fever. The evening of his entrance
kc Wis bled. He improved, the pain disappeared, and his appetite re-
turned On the Tth of August he had a relapse; hardly answered the
^jui'itious addressed to him ; remained motionless in bed; was entirely
pindjMd in the right arm and leg; was again bled. The next day,
Wi| oomatose, venesection was again practised, and twenty leeches
Wfif applied to the temples. On the 0th tho paralysis had disappeared,
httt, u ho was still comatose, another venesection was performed, and
Wtet'a leeches were applied to the nock over the jugular vein. On the
lOtliirtf bled again; still comatose, and the right arm contracted. On
*«* Wth bad epileptic paroxysms, during which it was remarked that
^iJde waa more convulsed than the other; coma profound; eighteen
to tlie jugulars; 14th*, 15th, and 16th, same symptoms; an
1 bed-sore on the sacrum. On the 18th coma less complete;
epileptic convulsions, especial ly in the night. From this time he con-
^^Ji^i to improve till the 28th, when coma again supervened, and on
titf *ath he died.

^h pi^»t -mortem examination the dura mater was found healthy.

*ia ijeiDg incised, a quantity of sero-purulent fluid escaped. The mem-

^ne was adherent to tho brain, principally on the convex surface,

tod e^cially on the right side, so that it was impossible to detach it

» ♦♦ nullitiii dv Tacad^ltuiti TOjaXv dc rw^deciue/' tome ▼», 1840, p, aC4.

220

DISEASES OF THE BRAIN.

entirely without rupture. On the? riglit side it formed a sac extending'
over about three-fourths of the convex surface, containing froin two
hundred to two liuntlred and fifty grammes of a greenish-white sero
purulent fluid. Another sac, coutaining from fifty to sixty grammes of
this fluid, existed on the left Bide*

The dura mater was removed, and it was ascertained that tlds fluid
oamo from the cavity of tho araclmoid and from the meshes of the pia.
mater.

In tho case of a gentleman under my charge there was intense head-
ache as the first prominent s\miptom, followed by epileptiform coni^ul*
sions, and varying degrees of paralysis, both of motion and of sensa-
tion on one side of the body and again on the other. When I first
saw him the optic nerves had been so injured by the pressure from
effused fluid as to cause complete blindness. Light coidd not be dis-
tinguished from darkness. The ophthalmoscope showed extreme atro*
phy of both nerves, probably either the result of pressure or the conse*
quence of neuritis from extension of the cerebral disease. The accumu-
lation of fluid was so great as to force open the bi-parietal, the fronto-
parietal, and the occipito-parietal sutures. Under treatment the excess
of fluid disappeared, the pain ceased, and he acquired the power of
vision to such an extent as to enable him to tell light from darkness^
and even to make out the figures on a bright carpet. He died, how-
ever, about six months after leaving New York, of cancer of the stom-
ach* *rhere was no post-mortem examination of the brain, or none that
was reported to me, but I am strongly of tho opinion that the disease
was chronic meningitis of the convexity of the brain, resulting in a large
effusion of serum.

Causes. — The etiology of chronic cerebral vcrtiealar meningitis la
often difficult to make out. Sometimes, however, the alTection is the
result of an acute attack. At times it clearly originates from blows or
fafls upon tho head, and again it is caiised by exposure to the heat of
the suii or to artificial beat. There is certainly a form of chronic in-
flammation of the membranes of the convex surface of the brain, which
is due to the extreme heat of the sun, not necessarily to tho action of
the direct rays, and which is characterized by the symptoms I have ^i^edr
fied- I see some cases of this every year in New York, and have wit^
nessed several similar instances in cooks and others whose oocupationa
necessitated the exposure of the vertex to intense or long-continued
heat.

The affection in question may also be induced by mental influencei
especially anxiety and other forms of emotional disturbance j and this
category of causes is probably the most influential of all others, with
the single exception of excessive alcoholic potations. So far as our
knowledge extends, this last is the most common factor in the causation
of chronic veriicalar meningitia.

CHRONIC CEREBRAL MEKINGITIS.

221

. .*'iis is another influential cause, though generalljr, as we shall
ie^: ' r, it acts preferably upon the basilar portion of the mem-

It if probably sometimes induced by rheumatism aod gout, and cer-
tiinly occasionally by tubercular deposit, but when arising" from this
led cause it is not to be confounded vnth tubercular cerebral
itis, the seat of which is in the membranes at the base of the
btmin, and which is otherwise differently characterized^

lOSis, — This is often impossible to be made out, with even a

it« degree of exactness, and is always more or less ilifficult. The

iffectioQ may be confounded with indammation and softening of the

oortica.! substance of the cerebrum, and the most careful study will in

many cases fail in discriminating between them. The tlifficulty is fre*

qinently heightened by the fact that the two diseases coexist. But we

ire much assisted by a thorough investigation, not only of the symp-

icm^ btit of the causes. For instance, a category of phenomena such

uhtis been given^ resulting from exposure to intense heat, is generally

da« to chronic intiamraation of the membranes of the superior surface

t^ the bruin^ and the same may be said of syphilis. When, however,

ihij symptoms follow undue mental exertion or emotional excitement,

tb* distinction is more ditHcult, and indeed in such cases the substance

of the cortex is usually also involved.

In general, the pain which is so prominent a feature in inflammation
nf tbe membranes, is not so marked an accompaniment of softening,
while in the latter the mental disturbance is greater than when the
morbid process is confined to the meninges, From inflammation of the
tQembranes at tbe base of the brain, the affection under consideration
i* distinguished by the almost constant absence of ocular paralysis,
4n<i bv the fact that the seat of the pain is different, and that the mind
i* moftj decidedly involved.

The ophthalmoscopic appearances will suffice for the diagnosis from
AMMnia or hyperaemia of the brain, or from megrim or neuralgia, even
i' tlif^ other points in the clinical history are not sufficient.

Prognosis. — The prognosis in cases of chronic inffaramation of the

fii'Tungea of the convex surface of the brain is decidedly unfavorable,

ynksi ii t\'philitic origin can be made out, in which event the prospect

fjf itvDver\^ is goocL But even in such a case the disease must be early

w|.jo<*ttHl to proper treatment, for the disposition to extend to the sub-

tt4flco of the brain which the affection so often manifests, and the fact

«>l new formations are liable to be produced and to exert an abnormal

rhe nerve-tissue, very greatly increase tbe probability of

result.

NeTeitbeJeas, I am satisfied that even where there is no suspicion of

ITpliifiii chronic vertic4dar meningitis is sometimes successfully com-

Thi* point will be further considered under the bead of treat-

222 DISEASES OF THE BRAIK.

ment. In the mean time I quote the following case from Dr. E, L,
Fox/ of Bristol, England, in which a post-mortem examination gave
evidence of the previous existence of the disease ' in question* It is
possible there was a syphilitic taint in this case, though nothing is said
on the subject:

" The patient, a young man, had died of an attack of haemorrhage,
from rupture of the right middle meningeal artery, but the dura mater,
all over the convex surface of the hemispheres, was somewhat adherent
to the subjacent arachnoid, while the arachnoid was thickened and yel-
low all over. This patient had been under Mr. Parker's care a year be-
fore, with great pain all over the upper part of the head, without any
delirium, and had been treated, with entire success, with iodide of po-
tassium. In this case, therefore, arachnitis had existed without any
lesion of the cerebral matter itself, and without delirium."

Morbid Anatomy and Pathology. — The essential features in the mor-
bid anatomy of chronic cerebral verticalar meningitis are hypersemia
of the vessels and a new formation of connective tissue by which the
membranes adhere to each other and to the brain, and by which they
are rendered opaque, and thicker than normal.

In addition, there may be deposits of exudation on the convexity
of the brain which, though intimately connected with the alterations of
the membranes, are yet distinct from them. These, as characterized
by Gintrac,* may consist of serum effused under the arachnoid, of a
thick, gelatiniform, discolored fluid in the same situation, of pus con-
tained either in the cavity of the arachnoid or infiltrated into the
meshes of the pia mater, of false membranes formed in the cavity of
the arachnoid, non-adherent, adherent to one or other layer of this
membrane, or double, composed of an external layer of the arachnoid,
and an internal, adherent to the visceral lamina, thus constituting cysts,
which may contain blood-serum or other matter.

Of one hundred and sixty-seven cases of meningitis of the convexity
of the brain collected by Gintrac — in which, however, the distinction
between the acute and chronic forms of the disease is not drawn — ^the
relative proportion of morbid conditions was as follows:

Injection, opacity, or thickening of the membranes 9

Serous exudation S3

Gelatiniform exudation 14

Pus 80

False membrane? 81

Total 167

Fox * has very clearly shown that tubercle may be associated with

* '* Clinical Observations on Acute Tubercle," " St. George's Hospital Reports," Lon-
don, 1869, Tol. iv., p. 61.

« Op, cit., tome il, p. 604. ^Op.filoe, eiL

CHRONIC CEREBRAL MENINGITIS.

223

exity of the brain, Tbe foliov

tieniogitis of the conves

cite from him, is so interesting in several respects, that I quote
it in f till, so far as the description relates to the brain :

^^Case XXII. — Ilenry B,, aged twenty-four, tailor; ill one month
with pain in the forehead; no cough. When first exajnined in recum*
brnt position, a sharp, blomng, systolic murmur was heard at the base
ol Ihe heart, traveling up toward the left shoulder; a little later he had
dkkli^ss, then intense pain, ehieQy at back of head. Head jerks back-
wait! nt every beat of the heart; much cerebnil throbbing- Temporary
ttiiei from blisters, cold to the head, and purgatives; but eventually
aore sickness, diplopia, which, however, was intermittent, and in-
closed headache. Then almost total freedom from pain, and all mor-
bid symptoms, and he was able to be out; but he died suddenly in a
fit, three months from the commencement of his illness. No broimng
of skin*

*^ Post-mortem Examinatiofu — Dura mater externally seemed healthy;
itttemally it was firmly adherent to the subjacent tissues at the spots
below mentioned; veins of convex surface of hemispheres tinged with
blood. On left hemisphere, about middle of brain, was a spot of tubcr-
cakms matter the size of a filbert, which seemed to be immediately con-
nected with the vessels of the pia mater, to have become adherent on
^ one side to the dura mater, and on the other to have extended
tb^ttgh the gray matter for a few lines into the white. The two lat-
ilil ind third ventricles much distended with clear fluid, containing a
fcif tmall, white flakes. Foramen of Monro enlarged suflTiciently to
t^taiti a small nut. Walls of ventricles very soft; optic thalaroi
tolrmbly firm. Corpora striata excessively pulpy; pons and medulla^
^iongsta everywhere rather soft. On anterior lobe of right hemi-
spUre, just on the lateral surface, was another tuberculous spot the size
of 1 nut. On the external surface of the cerebellum, close to the floe-
*'^m on left side, though not involving it, was a large mass of tubercule,
M'<n^ i5to the structure of the cerebellum, and uniting this organ to
'■^" pt>«tirrior lobe of the left cerebral hemisphere* More than three-
't'^f'tt'rs of the left half of the cerebellum were occupied by large ves-
•^w of the same growth, which apparently had grown separately, and
"7*T>duftl increase of size had at length beeome one mass. The dura
^t*r was adherent over a great part of this side of the cerebellum,
^ tiw> cerebellar structure that remained was almost diffluent. The
**^ side of the cerebellum was also much softened.*'

This case is remarkable, not only for the intermittenoe in the symp-
**>^t<i which Dr, Fox calls attention, but also for the lightness of the
FeoometiJi when compared with the severity and extent of the lesions^
^ch rpmiasions in the manifestations of cerebral disease as were ex-
TOtad in this c&se, though not unusual, are, m the present state of our
iBQwkdgie, not easy of explanation. For it is very evident that th^re

224 DISEASES OF THE BRAIN.

was a steady advance of the morbid processes up to the veiy instant
of death, and yet the patient died suddenly, having up to that time
passed through a period of almost entire freedom from pain and all
morbid symptoms.

I am tempted also to cite the next case from Dr. Fox's memoir, on
account of a like slightness of symptoms existing in connection with
extensive cerebral lesions.

Case XXI FT. — Catharine S., aged thirty-one, servant; single; pale,
lean v^oman; has had vertigo and pain in back of the head for five weeks;
no sickness, no rigors, pulse now very feeble and- hurried. Tongue
coated; skin hot; no sickness until eight days after admission, and she
coughed first on the ninth day. Became delirious, but was always capable
of answering questions reasonably, and the chief symptom was a gradu-
ally increasing weakness of pulse. Sank quietly out of life, without
coma, on the twenty-second day after admission, having had no convul-
sions throughout, and no cerebral respiration until the last day of life,

" Post-mortem Examination, — Cranium : Arachnoid, and subjacent
tissues on convex surface of the hemispheres, contained much clear
fluid, but were otherwise natural. Between the cerebral hemispheres
and the longitudinal fissure were a number of small, miliary tubercles,
and at the lower part of this fissure the opposed hemispheres were ad-
herent to each other by means of a mass of tuberculous matter the size
of a nut. A small portion of similar matter was found at the upper
part of tlie cerebellum, connected with the arachnoid. The venous
tissue around these tuberculous masses was very much softened and
ecchymosed. Two similar masses were also found in inner wall of pos-
terior horn of each lateral ventricle. Ventricles full of turbid fluid, and
their walls softened."

It sometimes happens that chronic inflammation of the membranes
of the vertex of the brain exists without the occurrence of notable
symptoms. Several such cases have come under my own observation in
which, after death, the membranes were found thickened, opaque, and
adherent, and in which, during life, no complaint of cerebral disturb-
ance had been made. It is probable, however, that symptoms of such
disturbance have existed, but have not been mentioned by the patient.

Treatment. — The treatment depends to some extent upon the cause,
although the general management of the disease is not subject to any
very essential variation, however it may originate. Thus the iodide of
potassium is in all cases the agent most to be relied upon. When the
affection is due to syphilis, or has followed syphilitic infection, the iodide
must be administered with much more persistency and in larger doses
than when not so associated. In all cases, however, it mi^st be given in
what may be called large doses, and must be continued for several
months. In uncomplicated cases the quantity administered may be at
first ten grains three times a day, gradually increased to thirty grains

CnEOKIC CEREBRAL MENINGITIS.

225

dose; but in syphilitic cases the doses will often liave to be
to eighty or even a hundred grains thrice daily. The iodide of
pot&sstmn should^ in my opinion, always be given in gradually- in creas-
ing doses. Thb is best efTected by using a saturated solution of the
Mificiiiie in water, each minim of which contains about a grain of the
mit. For the first day ten minims may be given three times, for the
ttflODd day eleven, and so on till the maximum dose, which it may be
JMoied proper to admlniater, is reached. I have several times had
c$9m under my charge in which no sign of amelioration occurred till
doses of from eighty to one hundred grains thrice daily were used.
Some one of the bromides may be very advantageously given in
to the iodide of potassium. The bromide of calcium is to be
in almost all cases. It acts more rapidly than the others, and,
ttDlwithstanding the recent opinion of a Gemian pliysician, more effect-
n&Uy. llie doses should be about fifteen grains daily, and each dose'
may be given with that of the iodide of potassium. It must not be
fofgotten that these medicines must, wheo taken, be administered
m a Urge quantity of water (half a tumbler, for instance). They act
baiter, and are less liable to irritate the stomach, when they are well
daotud.

Under the combined action of the bromide and iodide, the relief
bwB all 83miptoms of intra-cranial disease is often very striking. This
ifl opeeially apt to he the case when syphilis is at the bottom of the
nwrbid process.

Kelative to the propriety of administering mercury in chronic cere-
bni rerticalar meningitis, much depends upon the nature and duration
d tk« diaease. In non-syphilitic cases it is not indicated, nor in those
tastaacoi in which the syphilitic infection is remote, but, where the pri-
Wf diiotse is recent, mercury is of service as an addition to the other
'Wiilinss, It may be given in the form of the bitjiodide, or the bi-
wrida, in doses of the sixteenth of a grain two or three times a day.

tuf the relief of the pain, \irhich is sometimes very severe, a pill con-
^utiag half a grain of codeia may be prescribed with advantage, as
«h«o as required.

In regard to local medication, I am inclined, from more recent ex-
I^Q«ooM| to believe that blisters applied to the nape of the neck an*
^BBMlooally beneficial As a rule, however, I do not employ them, or
•■jrotker revulsive or counter-irritant means.

The patient should be instructed not to over-exert the mind, to avoid
^ ouiiea of excitement, mental or physical, and live in strict accord-
*te» with hygienic principles,

CURONIC n.VSILAR MENlNGFnS,

Qtronic basilar meningitis is very seldom the consequence of an
teaie attack, probably mainly for the reason that acute inOammation
15

226

BISEASES OF TOE BRAIN.

of the membranes at the base of the brain is almost invariably a fatal
affection.

Symptoms. — Although there is generally pain from the very incep-
tion of chronic basilar meningitis, the first very decided symptom is
aometimes an epileptiform paroxysm* Or there may be convulsive
movements of a limb, a group of muscles, or a single muacle, unat-
tended with loss of consciousness.

Again, there may be tonic spasms of the muscles of one or more of
tlie extremities, especially of the arms; or the muscles of the neck may
be simiJarly affected, causing the head to be fixed in an abnormal posi-
tion. The individual muscles of the face are not usually involveiL

But ordinarily the primary serious indication of intra-cranial dis-
ease is paralysis* This may appear in the head, arm, the hand^ or a
single finger; or one side of the tongue may be affected, giving rise to
defective articulation, and to a deviation toward the paralyzed side
when the tongue is protruded, or the muscles supplied by the seventh
nerve may be affected and facial paralysis be produced. In the great ma-
jority of cases, however, some one of the motor nerves of the eyeball is
first involved in the morbid process, and this is generally the third nerve
of one side, resulting in ptosis, external strabismus, and diplopia, dila-
tation of the pupil, and defective power of accommodation.

Sometimes the implication of the third nerve is not complete. Thus,
there may be paralysis of the levator palpebra? superioris muscle, pro*
ducing ptosis, or the internal rectus muscle of the eyeball may be par*!
alyzed, causing the globe to be rotated outward by the uncompensated
action of the external rectus, and as a consequence producing double
vision; or, what is more rarely the cAse, the superior or inferior rectus,
or the inferior oblique, may lose the power to act. In a few eases, tlw?
only indication of the affection of the third nerve is dilatation of the
pupil.

The fourth nerve may be paralyzed, and then the loss of power is ^
limited to the superior oblique muscle, and the ability to rotate the eye*
ball outward and downward is impaired; and again, the lesion is only!
manifested as regards the sixth nerve and the external rectus muaoleyf
so that internal strabismus is the result. Occasionally the first sign ofl
the disease is aphasia, with or without vertigo, confusion of ideas, or
loss of consciousness.

It not infrequently happens that pain of a very severe character ia
for a long time the only symptom which distui-bs the patieut. It may
be located in some part of the head, or may be referred by the patient
to the face, and is often regarded and treated as ordinary neuralgia.
Tlie chief features of this pain are its intensity and persistency, I have
known it to last, without interruption, night and day, for over four
months, driving its subject to the verge of insanity, and causing him to
entertain serious thoughts of suicide.

In a few of the cases which have come under my observation, the
principaJ symptom was anaesthesia of certam portions of the cutaneous
fiuface. The skin of the face appears to be particularly liable to this
pbenomenon, although I have seen it extend throughout the whole of
tme aid© of the body; again, confined to the lower extremities; and at
other times to the trunks or upper extremities. In one case this was
anaccompamed by paralysis of motion anywhere, but in the others the
ma»clc9, or some of them supplied by the third nerve, were paralyzed.
In a ease reported by P6trequin/ and cited by Lagneau,* of syphilitic
iiecioats of the frontal bone, and in which there was certainly also
cbroiue basilar meningitis, the lower limbs were deprived of sensibility
for two months.

Vertigo is almost always a prominent symptom, and may be so intense

♦mi persistent as to prevent the patient walking without support. At

times it is impossible for the recumbent position to be abandoned, even

Wan infant, without the supervention of severe dizziness; at others

it (occurs unexpectedly, and may be the cause of the individual falling.

The eyesight is often impaired from a very early period. This may

be clue lo paralysis of the accommodation, resulting from loss of power

ill the iris and ciliary muscle, especially the latter; for, though the iris

pfobably has some influence in effecting the adjustment of the lens for

Cifrcretit distances, it is in the ciliary muscle, as Von Graefe has shown,

tlat the function mainly resides. The defect in question is shown by

iW difficulty which the patient experiences in distinguishing near ob*

Jecta, There is no trouble in seeing images at a distance, but the effort

to road, for instance, is unsuccessful — the lines of print appearing

^Jampd — and always increases the pain in the head, besides inducing

*'"D»pararT pain in the eye. The exact degree of impairment of accom*

ruoiiatite power may be ascertained by the use of Snellen*s test-type,

^JTstiB better by Galezowski's typographical scales,'

Oriiie asthenopia may be the result of the paralysis of the internal
fwetiis muscle.

Again, the defective vision may be caused by the disturbance in the
ipseial nervous apparatus of the eye. Examination with the ophtbal-
momiape almost invariably reveals the existence of hypersemia of the
optio nerre and retina, and not infrequently of optic neuritis, caused
hfexietmon of the morbid process from the cerebral membranes to the
op^ tuirre* Sometimes, as in cases ta be cited presently, vision may
ba entirely lost from this cause; but^ again, it is indubitable, as Dr.
Iltigiiltngs Jackson has very definitely shown,* that a great degree

t &mtiU Miiii«alt dt PartM, ISSO, tome ir., p. 648.

* * tlalarfifi sj|ihUitiqu«i du ffst^e aerreas,*' Paris, lSd(\ p. 418.

' "iobdlet tjpogrmphiqtiGS et chronoitlqiies poar rexamea de Tacmtd riraellef** Bmxa^

; o«b«r plAoeii in the Wost RIdfng Liioatie Aijlma Rsports, ta a paper eati-

DISEASES OF TQE BRAIN.

of optic neuritis may exist, and yet the patient be capable of mintite
vision.

The sense of hearing may also become inipaired or lost by extension
of the infSammation so as to involve the auditory nerve. Seyeral
cases of the kind have come under my observation; and in one, which
will be more speciiiGally referred to hereafter, the function was very
suddenly regained under appropriate treatment.

Although mental exeilion of all kinds adds to the severity of thd
symptoms, it is not usually the case that the mind is primarily affected
to any considerable extent. There may be periods of depression but
these are generally the result of the physical phenomena — the pain, ver-
tigo, paralysis, etc., the sensations arising from or the contemplation of
which are calculated to disturb the mental equanimity. When, how-
ever, the mind is brought to bear upon any subject, the intellectual pio-
oesses are as correct as ever, the only difference being that they cannot
be long continued without the supervention of fatigue and an aggrava-
tion of the symptoms.

It quite often happens that the seat of chronic basilar metiingitia
changes, and with tlio transference there is an alteration in th^ locality
of the symptoms. This is especially seen in the matter of paralysis.
Thus, in the beginning, the third nerve may be paralyzed, and eventu-
ally the extension of the lesion leads to the imphcation of the fourth,
fiftli, and sixth. Cases in illustration of this point, which have occurred
in my own experience, will presently be adduced. In the mean time, the
following example from Sir Charlos Bell * will prove of interest. The
fact that Sir Charles mistook the real nature of the disease will not de*
tract from its importance. It is reported as a *' Case of Disease of the
Nerves within the Orbit.

" Martha Symraonds, aged forty-one, Northumberland Ward* This
woman was admitted into the hospital for a disease apparently seated in
the left orbit, Nino months ago she had a para]}i:ic stroke, attended
with the loss of power in her left arm, neck, and face, on the same side.
She lost also her power of speech, excepting only to * babble,' as she
says. She recovered from this attack, and went into service. About
eight or ten weeks ago, she was alarmed by a commencing dimness in
both her eyes, and she was obliged to leave her place on account of this
dimness of her sight. Both her eyes were equally affected, and there
was no redness or opacity perceptible in either of them. She placed
herself under a medical gentleman, because she dreaded a return of the
palsy. About six weeks ago, the upper eyelid of the left eye fell, and

tied " A Case of Recovery from Double Optic NeuritJa.** The Cttfle was probAhlj one of
chronic biisilar lueniDg^itia, of syphiUlie origin.

' " The Nerroug System of the Hamau BoJj. Embnicing tho PApers dcli?efvd to th«
Rojal Sociutx on the Sal^ect of the Nerves,^' Loadoo, 1830. ApfKmdix, p. cr. Edltioo of
lMi,p. 34S.

CHRONIC CEREBRAL MENINGITIS.

229

d not raise it. At that time sbe suffered great pain above th©
and the pain extended upon the left side of her forehead* She
■I the tame time lost the vision of this eye^ although she could dU-
liigiitsh by it the light of day from darkness. She could direct the
flKilions of this eyeball as well as of the other at that time, and the ap*
pearance of the eye was natural.

** Five days before she was admitted to the hospital she experienced
a violent, deep, throbbing pain in her left eye, and from that time the
ejfrbftll, as she says, became enlarged, until it projected considerably
beyond tlie orbit. Two days before her admittance, she was totally
blind in that eye, and was deprived of sensation on the surface of the
whole eye, eyelids, the internal corner of the nose, and upon the left
lide of her forehead.

** At present her left eye is covered with its upper eyelid, and pro-

|kU greatly from its natural situation. The lower eyelid is everted as

a oooaequence of the projection of the ball of the eye, and the conjunc-

litl Is tumid and projecting, Slie cannot raise the upper eyelid, although

^Am it 18 raised with her finger she cun squeeze it down again, and

•inlci with a motion which corresponds naturally with that of the other

(•ye. It may be a question whether the globe of the eye is enlarged|

or only protruded. The pupil is unnaturally large, and the iris is

without motion. She cannot move the eyeball in any direction. The

wholu <^ye is insensible; she has just had her lower eyelid scarified, and

A$ Wfts not sensible of pain. She allows us also to press with our finger

' surface of the eye, without complaining of any pain, or winking;

ijjjh, as we said above, she can still wink, and does wink with this

mlid when the other eye la threatened,

*' Octolter Gth. — To-day some further examination was made of this
vobuqV face and head, in order to ascertain the extent of insensibilitv.
« ^u sUktf^d in our last report that she has lost sensation in the sur-
fic^ of the left eye and eyelids, in the comer of the nose, and upon the
^TeWnl In these parts, she says that now the loss of sensation is less
•roiplete, because when she had her eyelid scarified, the other day, she
Mtpain, which she did not when it was scarified before. The eye also
^"^iBu diminish od ili size.

** Besides those parts which we have already described as being af-
^*pM, she has, in a partial degree, lost sensibility to touch in that part
^'f "ft cheek which is just under the orbit, and downward upon the side
"^W nose, and upon the left side of her upper lip, and also within the
'*''% of the nose on the left side* However, when the point of the
P"* Was brought near to the ear, or upon the skin which is over the
•^^ jaw, she then was sensible of pain, A piece of linen was twisted
•otAat it might be introduced into the left nostril; she allowed us to
pwk it upward as far as we could, and, during this operation, she only
'viQsrked that she was sensible of its presence. Turning it about with-

^^^^H

230

DISEASES OF THE BRAIK.

in her nostril did not make her sneeze. ^Tien we tried the same
periment on the other nostril, she was unable to bear the ticlcling pro-
duced by the loose threads of the cloth, before it was introduced into
the nostril. Now she informed us that she is in the habit of taking
sntiff ; and she is not only insensible to its usually agreeable effects, but
uneouscious of its presence in the left side of tlie nose. We next made
her close her right nostril, and inhale strong spirit of ammonia j and
then repeated the same experiment on the other nostril. There was a
very obWous difference in the effects produced by the ammonia on the
two sides of the nose. She told us she could smell the ammonia on
both sides, but still she could not bear to hold the bottle containing
the ammonia so long at the right nostril as we observed that she
could at her left. When the bottle was placed under the right nostril,
its pungency affected her almost immediately, so much that she could
not bear it; on the other hand, she allowed it to remain for a consider-
able time under the left nostril, and even snuffed it up strongly before
she was inclined to remove it. During these experiments, we observed
that the right eye became suffused with teiirs; the left eye, on the con*
trary, appeared to be dry on its surface,

'*' In order to ascertain further to what degree her sense of smelling
was affected, we tried the effect of some substances which possess odor
without pungency. On applying oil of anise-seed to her left nostrO,
while the right one was shut, she inhaled it powerfully, but was sen-
sible of no smell. Then a piece of asafoetida was tried, but still she bad
no kind of sensation, either pleasant or the reverse. She was sensible to
these odors io her right nostril.

"The state of her mouth was examined; with the point of a pencil
we pressed against the upper gums, on the left side of her moutl), and
the inside of her cheek, where it is reflected off the gums, and she ap-
peared to have very slight or no sensation at all. She volunteered to
put a spoonful of mustard between her gums and her cheek, and she
seemed very little incommoded by such an experiment. The sensibOity
of the other parts of her mouth was natural.

** The circumstances of this ease," continues Sir Charles, " make it
difficult to determine exactly where the disease is seated, which thus
produces the destruction of the optic nerve, the third and fourth nerves,
the first and second divisions of the fifth nerve, and the sixth nerve.
Among tliese nerves we might add the olfactory nen'e; but it may be a
question whether the function of that nerve is directly or indirectly
affected: the issue of the case will probably determine this matter.
However, from the condition of the parts without the orbit, we observe
that the power of closing the eyelid and winking is retained, when the
power of raising the eyelid is gone, and the sensibility of the eyelids
ami of the eye itself is completely lost. It is the portio dura which is
distributed to the orbicular muscle of the eyelid, and bestows the power

{

CnRONIC CEREBRAL MENrKGlTIS.

931

tig. We see also that she can iahale powerfully^ and can per-
iy move the muscles belonging to the nostril and upper lip of the
Mt side, when at the same time the skin which covers these parts is
tnieiiSLble. StilJ, that power belongs to the portio dura. This oerye,
piBStD^ to the face by a circuitous way, and being, therefore, uninjured
by firessure within the orbit, permits her to move the left nostril and
oda of her mouth in a natural correspondence with the other side of
lier face, although both the first and second divisions of the fifth nerve
are included in the disease, and are destroyed along with the first, sec-
ond, third, fourth, and sixth nerves.

" Jlfa^ 20, 1829.^ — Since she left the hospital she has been a constant

The pain in her head has never left her; it is principally

; orer both her eyes, and over the left in particular* For three

yiift ihe has observed that this pain is aggravated for a fortnight be-

fow hftt monthly periodical return; she says she does not know what

to do> her suffering is so great. The pain varies in a remarkable man-

nf»f with the changes of the weather: she knows when rain is approach*

bg by the increase of the pain, and immediately after it is over the

p*bi IS relieved. She has not had a return of the loss of speech, or of

ibe p&mlysis of her arm, since she left the hospital, but she has had fits

ind «ho has suffered from cramps in the back of her neck and right

bre«at» The ann, which was formerly paral}^ic, becomes, about once a

Dttonth, numbed in such a manner that ahe cannot use her fingers, and

tiiii is aocompamed with great pain. These attacks do not last for more

thtn five minutes. She walks quite welL

"The loss of sensation is principally in the forehead; when pricked
*^Ui % sharp point in any part as high up as the crown of the head, she
Us no feeling; but In the temples, and below the orbits, and on the
<iOft| ihe retains sensation. The left eye is blind; the pupil large and
tQnxkOf&ble; the motions of it are gone; the surface is insensible; it ia
dfltr» and it remains fixed in the centre of the orbit."

His woman entered the Middlesex Hospital in October, 1824. Id
tie thifd edition of Sir Charles Beirs work, published in 1844, the fore-
gob^ particulars are given, and the history is resumed by Mr. Shaw, aa
hi obsenrad her in June, 1B36« At this time there was no marked
filHUBgc*, except that, from an inflammation of the right eye, she had lost
Ite S^tt, and had become entirely blind.

'Hi^t this case was not one of disease within the orbit is sufficiently
appftreni from a consideration of the symptoms, almost all of which
potat to intra -cranial lesion. The extensive paralysis of motion and of
■ibility, the epileptic convulsions, the cramps, the aphasia, are so
ay ctrcumstances against the correctness of Sir Charles Bell's diag-
Tliat the morbid condition was inflammation of the basilar surface
of tiio oerabral membranes is extremely probable, as much so upon the
I of exetu^n as from a consideration of the positive symptoms.

232

DISEASES OF TQE BRAIN.

ItliH

In a case which I saw in consultation with Dr. H. Knapp^ of this
city, the patient, a youog^ man, in whom there w^as no history or even
suspicion of syphiliB, was attacked with severe pain in the head, at-
tended with dimness of vision iii both eyes. In the next place the
third pair of nerves became involved, causing paralysis of all the ocu-
lar muscles supplied by these nerves on both sides, and of both eyelids,
and also producing dilatation of both pupils. Next both fourth nerves
were affected; then the fifth pair causing facial anaBsthesia and paralysis
of the temporal and masseter muscles on both sides; then the sixtb^ and
eventually the seventh and eighth^ resulting in paralysis of both exter*
nal recti muscles, double facial paralysis, and loss of hearing io both
ears* There was, therefore, in this very remarkable case, a gradual ad'
vance of the morbid process, through a period of several weeks, aJoi
the base of the brain, from the anterior to the posterior region. With
all these symptoms there was not the slightest mental derangement j
neither was there paralysis of any other museks than of those supplied
by the nerves specified. Shortly after I saw, him the pneumogastrio
nerves became implicated, and death soon ensued. Unfortanat^ly,
tiiere was no post-mortem examination, but Prof. Knapp and myself
agreed that the case was one of inflammation of the membranes ooveir*
ing the basilar surface of the brain.

In the case of a woman who came to my cliniquo in the winter of
1871-72, tbe principal symptoms wei'e deep-seated pains in the head,
vertigo, and i)aralysis of the third nerve on the left side» as evidenced
by ptosis, dilatation of the pupil, and external strabismus, tlie latter
condition producing diplopia. Conjoined with these symptoms there
was slight but decided paralysis of the muscles of the face, arm, and le^
of the opposite side, together with cutaneous anjesthesia. Inquiiy
showed that these symptoms had been of very gradual development.
There was no history of syphilis in the case. I was of the opinion that
the disease was chronic basilar meningitis, and gave an unfavorable
prognosis; prescribuig, however, the iodide of potassium in large doses.

The following year she returned, but this time the sixth nen'e was
aifected, causing internal strabismus; and the ptosis, paralysis of the in-
ternal rectus, and the dilatation of the pupil, had entirely disappeared^
The other symptoms had for a time been very greatly relieved by the
treatment, but had reappeared in considerable intensity about two
months previously.

In another instance, this migratory character of the disease wa»
well shown. The case was that of a young man, a private patient, but
whom I showed to the class attending my clinique. He came to me
originally with external strabismus, ptosis, and dilatation of the pupil
of the left eye, together with defective accommodation. Examinatioii
with the ophthalmoscope showed the existence of optic neuritis, rather
slight in character, but yet decided, in both eyes. He had also the most

I me
tupil J
tton H
ther I
nostfl

CERONIO CEREBRAL MENINGITIS,

233

eiy ngonuiug pain in the head that has ever come under my ob-
3on, with vertig-o, frequent attacks of vomiting", and paresis if
Aol paralysis of the left arm and leg. A consideration of his condition
ltd me to the diagnosis of a cerebral tumor, and I accordingly gave a
tilj unfavorable prognosis. I was led to this conclusion not so much
fnm the ttiotorial derangement, as from the atrocious cephalalgia from
vkiidi the patient suffered. In this case there was some slight suspi-
ooQ of syphilis, and I treated him with mercury and large doses of the
io£de of potassium* In a short time the pain in his head disappeared,
omI in a few weeks there were no indications of paralysis anywhere j in
hm^ be was to all appearances perfectly cared, But at the end of two
nr tht^v montha he reappeared, with the corresponding set of symptoms
ia the right eye and right side of the body, and with pain in the head
faDy a« »erere as that which had characterized the previous attack. I
igaiu treated him with mercury and the iodide of potassium, and his
iflDptoma again disappeared. He remained well for two years, when
fat had another attack, of which he was entirely relieved by the iodide
d |>otaiatum«

la thiii case, the history of which points strongly to a syphilitic
wigiOf there were probably inflammation and thickening of the mem-
bnats at the base of tlie brain, and presumably gummy formations.

Tbc fact that the inflammation sometimes alternates with skin-enip-

tiom ii interesting, and has been repeatedly noted. A case of the

kiad was oot long since under my care. It was that of a gentleman

wkobad attacks of acute pain in the head, accompanied with al! the

pbeDoaicaa of paralysis of the left third nerve. There was effusion of

L'f: ill upon both optic disks, the result probably of old optic neuritts.

CuTiijuily enough, these attacks alternated with an edematous affec-

tioii, iafolvin^ the trunk and especially the breast. On the lUsappear-

*w*nf the skin-disease under remedial measures, his huad-symptoms

immeifiitely recurred, and, when they were relieved by the action of tl>f*

! ot potassium, he was again attacked with eczema.

' •: flu' f-rtv-seven cases of basilar meningitis colWeted by Gintrac,'

' r r'j ■n were distinctly chronic in character. As post-mortem

.^11 wore made in these cases, they will be more appropriately

1 [ i iirt i»>r the head of morbid anatomy and pathology,

f i lit^s.- 1 he causes of chronic basUar meningitis are generally

I' niiy apparent. It may result from an acute attack, but this

^' • t & ujrtial mode of origin, for the reason already stated, that death

^oriiaarily the consequence of such an affection. The most oommon

'*''•** uce is syphilis; next, the inordinate use of alcoholic

"IttOr^. %oe8sive emotional disturbance, such for instance as

"*»iaet8 aoaietiei. Then next in point of frequency come atmospheric

^i^Mitiidea, blows on the head, and attacks of other diseases, as scarlet

' Op, rt^j lorue il, p. 67 7»

DISEASES OF THE BRAIX.

fever, and especially epidemic cerebro-spiiial meuingitis, and suppv
live otitis. Men are more subject to it than womenj and adults
than children. Frequently no cause can be assigned.

Diagnosis. — ^Chronic basilar meningitis is not liable to be
founded with any other cerebral affection except timiorsj especially
those of a syphilitic character, situated at the base of the brain, and
chronic softening, arising from thrombosis of the basilar arteries, an^
diseases of the capillaries.

From iion-8\'philitic tumoi-s it may be distinguished by the fact thai
the paralysis is less extensive, that the pain is not usually so sever
that the vertigo is not so intense or persistent, and that the
turbances of vision are not so profound. In a word, the symptou
chronic basilar meningitis are less pronounced than those of tumc
the base of the brain, while at the same time they are ordinarily de-
veloped with greater rapidity* Another mark of difference is the fac
that tumors, non-syphilitic in character, do not yield to remedial me
ures, while chronic basilar meningitis often does, and is generally mitii
gated by proper treatment.

From tumors of a syphilitic nature, or gummata, as they are caUedpl
the diagnosis is difficult, if in fact there is any real distinction existing
between them and basilar meningitis of syphilitic origin. A gummj
tumor situated at the base of the brain can scarcely exist without thfl
production of basilar meningitis, so that the syuiptoins such as hav«
been described, present in a person having the clinical history of syphi^
lis, are either the result of simple chronic meningitis, or of meningitis/
associated with one or more gummy tumors, Virchow * goes so far as ta ^
doubt if even, where after death we find only meningitis, the condition ]
has not been preceded by a gummatous affection which has disappeared.
The further consideration of this point will be more proper under the ,
head of morbid anatomy.

Where there is no history of syphilis, of course the question of the
existence or non-existence of syphilitic tumors will not arise.

From thrombosis of the arteries at the base of the brain, and from \
such diseases of the capillaries in the same situation as have been de-j
scribed in the previous chapter, chronic basilar meningitis is scarcely
distinguishable during the life of the patient, WTien these are syplu*
Jitio in character, the two conditions generally coexist. Sooner oti
lat^r, however, the former affections terminate in death, and the phe
nomena to which they give rise, though sometimes remitting in violene
are clearly not lessened in severity by medical treatment. As regar
other affections, the history of the case will generally be a sufficient
guide to a correct diagnosis.

Prognosis. — The prognosis is very much influenced by the ctiologyJ
Those cases which result from injuries generally terminate fatally, as dc

1 "Pathologic des tumeuw, traduit de rAUcmaad/' Paria, 1869, tome iL, p. 440.

CHRONIO CEREBRAL MENINGITIS.

235

ae to tbe excessive use of alcoholic liquors, especially if the habit
lued. When induced by mental influences the prognosis is
getUifmny^ more favorable, provided the patient can be subjected to the
bygieDic operation of rest, travel, chang^e of associations, etc. Syphilitic
Umlar meningitis, if seen sufficiently early and subjected to proper
lreftt]ii«ent, usually terminates in recovery. Subsequent attacks, which
•re always liable to occur, do not in general run so favorable a course,
I In ail cases a great deal depends upon the duration of the disease,
en of long standing the morbid changes in the tissues involved have
Jy become so profound that recovery is not a probable sequence.
The ag« of the patient is likewise an important point in the prog-
i I and, other things being equal, individuals of advanced years are
\wo apt to recover as those of middle life. In children a fatal temii'
^ mlioti is to be expected.

Those cases which are due to the extension of iiiHammation from tlie
I Mr almost invariably end in death, as do those ensuing upon epidemic
ombio-spinal meningitis. Latterly, however, I have had under my
Aug^ two cases, resulting from cerebro-spinal meningitis, in which it
lai taken place, though with yery marked impairment of vision from
douUe optic neuritis in both, and of hearing in one,

lofbid Anatomy. — The morbid anatomy of chronic basilar menin-
ptis docs not differ in many respects from the corresponding affection
d tliQ cooTex surface of the brain. It is, however, generally much
\ einsumscribed in its extent, and may bo restricted to a portion of
fei Baenibrades not larger than a dime in circumference* In one form
%ifeetod tissues are thickened and opaque, and there is an exudation
of KTooa or gelatiniform Buid ; in another the exudation is puriform ;
uhd ta t third it is thick and gummy, constituting the so-called gummy
tiunor of syphilitic origin.

Tbi lerous or gelatiniform exudation often shows a tendency to be-
®ww tiigaaized and to present a membraniform appearance, or even to
MRUW a still more solid form, Gintrac cites from Simon * the case of a
^DQiOi thirty-five years old, who for six years had been subject to
limijviis of intense cephalalgia. Two years subsequently she became
Uiad on the left side, and for two months afterward suffered still more
•Wtfdy from pain in the head ; then she lost the sight of her right eye.
«W iridfia remained contractile. The sense of smell was lost, though
^ pituitary membrane retained its tactilo sensibility. Hearing, taste,
*^ touch, were unaffected. Coma supervened, in which she died. On
'Umtfiatian, the diplOe and the membranes were found congested*
*•• ftitchooid and the ventricles contained an excess of serous exuda*
^^ la the pia mater there was a deposit of a whitish-gray fibrinous
•■■tMioe which followed the course of the middle cerebral vessels, and
*FQTtr the i^hiatma of the optic nerves, the tubercula mammiilaria, and

' *'BalleUa de U soci6t^ ftnatomiquc^'* 1815, p. 196.

236

DI6BASBS OF Till: BRA IK.

les

.lie

I of I
butM

the £Lfiterior perforated spaces. The optic aod olfactory nerves were
atrophied and the chiasma deformed ; the retiiiiu were norroal.

Usually the membranes are, in some places, firmly adherent to eaci
other, and not infrequently to the cortical substance of the brain^ i
which case the latter is softened to such an extent as to tear awaj:i
when the attempt is made to separate the membranes from it,

Wlien the exudation is puriform in character it occasionally becomes
thick, and appears as semi-solidified plates in various situations.

The exudation, whatever its nattu'c, may be deposited betwv.*en the
layers of tlie arachnoid, in the sub-arachnoid space, or io the meshes of
the pia mater. Its seat may bo any part of the base of the brain, bul
its usual situations are the chiasma of the optic nerv^es, along- the cou;
of these nerves, on the tuber cinereum, the cor|>ora mammillaria, and
tween the crura cerebri. Sometimes it extefids anteriorly along the
course of the olfactory nerves, laterally into the fissure of Sylvius, and
posteriorly as far as the pons Varolii and medulla oblongata*

In the syphilitic form of the disease it is a matter of some doub^
whether ihe gummy exudation is the result of the specific inflammatL
of the membranes or whether the ioflammation is excited by the pi
cncc of the now formation. Gintrac' seems inclined to doubt the ex'
istence of syphilitic meiiingitis, though he admits the possibility of iti
occurrence. For him there is no syphilitic meningitis unless its pres*
ence be demonstrated by a post-mortem examination and its character^
btics definitely established, while others give a specific nature to any
mflammation of the meriiogea — and, in fact, to any other aflfeetion —
occurring m a person who, at any time, has been the subject of syphilis* i
In my opinion, cerebral meningitis may be induced by the syphilitiofl
diathesis, and thus be a syphilitic meningitis, and it may exist as a non-™
specific affection in an individual who has had an infecting chancre.
Undoubtedly there are cases of meningitis occurring in syphilitic per*
sons that are no more under the influence of anti-syphilitic treatmenl
than the cases happening in otherwise healthy individuals, Fox,^
however, states it as his opinion that it is at best an open quc^tioo
whether meningitis ever occurs independently of syphilis, rheumatism^
alcoholic poisoning, tubercle, arifemia, or mechanical irritations.

But, in regard to the morbid anatomy of chronic basilar meningitis
of syphilitic etiology, Virchow * has supplied very important data in his
remarks on syphilitic tumors of tlie brain and its membranes,

The gummy tumors are seen most frequently at the base of the hi
Sometimes they are very exactly defined in their boundaries, and
they are tumors in the true sense of the word ; but ordinarily they air
more difiTused, and are accompanied with the phenomena of inflamma-

» Op, «/., tome ilL, p. 100,

' *' The Pntliological ABatomj of the Nerv<}Uft Ctmtres,'* Loadon^ 1674, p. 4fiw

» Op. €U,^ p. 437, <rf uq.

CimOXIC CEREBRAL MENINGITIS.

237

&t wbich seems to distinguish them from the true tumor. As
Ued, Virchow regards this condition as a '*" gummy inflamma*
r»^ and even when the exudation is not present, and the appeal^
mre those of a non-speciBc Inflamomtion of the membraDes,, the
ion may arise whether or not the gummy exudation has not been
Am firet step in the morbid process, but, haviog been absorbed, has left
arfy doabtftd traces of its presence. With the true gummy tumor we
tre not at present concerned.

The most common seat of syphilitic basilar meningitis is the region
booiKfed anteriorly by the cbiasma of the optic nerves, and posteriorly
by th^ entra of the cerebeUum. Hence it Is that the nerves lying at the
hmm of the brain, and especially the third pair, are so liable to be im*
pfiesiktcH). This latter, from its exposed situation, running as it does
from the crura cerebri to the orbit^ can scarcely escape being involved
m the morbid process,

Ptthology. — The functions of the nerves at the base of the brain are

10 wfcll understood that the connection of the symptoms of chronic

builar meningitis with the morbid condition constituting the disease is

nffideatly apparent in the great majority of cases. The circumsenbed

iktrMTtf^r of the inflammation enables us also to determine its seat with

loeumcyf and its migrations can be marked with considerable certainty.

Prohftbly in the very earliest stage of the disease these points cannot

lIwAti be clearly made out, for the principal phenomenon is centric

ptb, due to congestion, and it is difBcult to locate tlie seat with exact-

iym\ bttt, as the affection advances to its full development, effusion

tikii place, and then the eccentric symptoms become more prominent

if t^0)r do not at this time make their appearance. These we have seen

tOQitst of disturbances of sensibility and of motility in those parts of

tebody supplied by the nerves at the base of the brain, or of aphasia

fcoia llitt extension of the inflammation along the fissure of Sylvius to

tiiniibuid of Reil, or parts of the brain in its immediate vicinity. It is

*n»W At a still later period, when the mori)id process has directly or in-

4rr ved the substance of the basilar surface of the brain itself,

4ii .-,..,„iy or motility is disturbed in the trunk and limbs.

When the sense of smell is deranged, the lesion exists upon the same
^ u the symptoms, for, as we know, the olfactory nerves do not de-

When vision is impaired from optic neuritis, we cannot be so sure as
^ih» tide npon which the disease exists. For we may have optic neu-
mu the consequence of disease in distant parts of the brain, as well
^bam the direct implication of the optic nerves in the pathological
^Ottlilioii ; and even when this latter is the case, owing to the in-
QNBplHo decussation of these nerves, it is possible for optic neuritis to
ts&t iQ conjunction with a homolateral or a heterolateral lesion*

The iymptoms due to the involution of the third pair of nerves arc

238

DISEASES OF THE BRAIN.

maDifested as regards the upper eyelid, wliicb becomes paralyz
drops over the eye, the muscles of the globe, except the external rectus,
and the pupil, which is dilated, owing to the paralysis of the circnla
fibres of the iris, which receive their motor influence, through the thir
nerve, from the ophthalmic ganglion.

The third pair of nerves have their apparent origin in the crui-
cerebri, the right nerve from the right cms, and the left nerve fron
the left crus. If, however, the fibres be foUowed out by minute di
tion, as has been done by Vulpian * and others, they are seen to be
ranged into three groups. Of these the middle and posterior decussat
after passing entirely through the crus, while the anterior group pa
forward to the optic thalamus, in which ganglion the fibres are los
None of the fibres of origin originate in the crus, and this latter mmj
be entirely dissected away and the third nerve be left intact. Now, if
Vulpian be right in his view — and there is no doubt now upon the sub-
ject— ^that a coDsiderablo number of the fibres of origin of the third
nerve decussate, any disease of the brain affecting these fibres must be
manifested by derangements of motility of the nmscles supplied by tb
nerve of the opposite side, and, as the motor and sensory fibres of tb^
apinal cord decussate below the point at which the third nerves dectia<
sate, the disease, if causing paralysis of other parts of the body, woul
induce this condition also on the opposite side; or, in other words, on the
same side with the paralysis of the muscles supplied by the third nerve,
Each cms cerebri contains the motor and sensory fibres which ooi
from the opposite side of the body, below the medulla oblongata* II
also contains the fibres of the corresponding third nerv^e. Disease ii
volving a crus would therefore cause derangement of motility in th«
muscles supplied by the corresponding third nerve, and of sensation and^
motion in the opposite lialf of the body ; alternate or cross paralysis
would therefore be the result. As chronic basilar meningitis often In-
volves the membrane covering a crus, cross-paralysis is frequently 4
phenomenon of the disease.

In those cases in which there is no paralysis anywhere except in tW
muscles supplied by the ocular motor nerve, the lesion must exist ante-
riorly to the crus, and affect the trunk of the nerve of the same side aa
that of the paralyzed muscles*

It is not often the case that the fourth nerve, or trochlearis, is alone
involved ; though one such case has come under my observation, la
this the patient had no marked symptom of any kind, except that in
certain position of his head he saw double. On examination, I aseei
twined that, when he turned Ins head toward the left shoulder, be saifj
double, and hence I diagnosticated paralysis of the left inferior oblique
muscle. Further experiments confirmed this opinion, ajid the diagnosis
of chronic basilar meningitis was shown to be correct by the extension
* *' E«sai sur roriginc de phifiieurs pairefl dec nerfs craniens.'"' Tb^te de P*n>. \^^X

CHKONIC CEREBRAL MENINGITIS.

239

disease so as to involve the third nerve, and by the stiperrention
fia %ad other phenomena of the aiTection in question.

I sixth nerve, or abdacens, Is not infrequently the only nervo
in the lesion, and then there is internal strabismus from
dywoB of the external rectus muscle. Several such cases, in which
were the concomitant symptoms of chronic basilar meningitis^
ive oome under my notice. The case of one of these, a woman, who
the subject of a clinical lecture^ has already been cited, An-
'flilier cmse was that of a man, the subject of syphilis, and in whom the
was only manifested as regartled the external rectus muscle,
> were no head-symptoms of any kind. The paralysis had ensued
tlae nighty and the patient awoke in the morning to find that he
I ialernal strabismus and double vision. He recovered entirely nnder
te use of large doses of the iodide of potassium. But on the 10th of
klKiaty, 1875, he had an epileptiform paroxysm, and this was several
tines repeated during the following week. Under the influence of the
iodide of potassium, conjoined with the bromide^ he has for the past two
aamhs had no return of the convulsions ; but his mind is somewhat
«0lifufl«d^ and he has occasional severe pain in the head.

The seventh, or facial nerve, is sometimes embraced in the morbid
pfDQet% ^ving rise to paralysis of one or more of the muscles on one
fide ol the face, which it supplies. In one instance, apparently the re-
odl of sj-philitic basilar meningitis, which came under my charge in
Dtoomber, 1874, both facial nerves were involved, and there was conse-
fMatly double facial paralysk.

The eigiith, or auditory nerve, also occasionally gives evidence of
Imi or impairment of its function ; but, unless special examination rela-
Imio the hearing bo made, or both nerves bo involved, the lesion, as
tsfuds this nerve, may escape detection, as patients very often, even
*Ken the hearing is entirely destroyed in one ear, are unaware of the
Ua, aad persist that it is unimpaired.

The iiitith, tenth, and eleventh pairs of nerves are not so apt to be
l&cted in chronic basilar meningitis as some of the others, for the rea-
■ow that their relations with the interior of the cranium are not so in-
*Bna^ and that the seat of the disease is generally anterior to their
ibtttioQ.

Sbould tlie ninth, or glosso- pharyngeal nerve, be involved, there
^^vld bo loss or impairment of the sense of taste upon the corre-
Voodtotg stde^ and the implication of the pneumogastric would lead to
i ooniplicated series of phenomena, of which the chief would be pal-
litlCiQii of the heart, irregularity of the respiration, and d«*rangement
4tbe function of digestion; while, if the spinal accessory were reached
Ijf this morbid process, there would be difHculty of swallowing, and
peylapi aiteiation in the timbre of the voice.

Hie hypoglossal, or sublingual nerve, is occasionally alTected, pro*

240

DISEASED OP TEE BRAIN.

ducing paralysis of the side of the tongue corresponding to the sitd
tion of the disease.

When the fifth nerve is involved, the chief manifestations of its
lesion are relative to sensation. Thus there are either intense neuralgic
pains in some part of the cutaneous surface of the head or neck, or
there is equally well-marked amesthesia. The former condition is by
far the more frequent. From some cause or other, the motor fibres of
this nerve almost invariably escape, and thus the temporal and masseter
muscles are not paralyzed, I have, however, already cited a case
which they were affected.

The general relation of the symptoms of chronic basilar meningiti
with the lesion constituting" the disease is well shown in several of th^l
cases cited by Gintrac, Thus he quotes one from Bossu,' that of
man, twenty-four years old, who from exposure became affected with
headache about the supra-orbital region, vertigo, noises in the eara^
facial neuralgia, and muscular contractions. At the end of a year he
had vomiting, want of appetite, general debility, and a continuation of
the supra-orbital headache. There w^ere also amblyopia, diplopia, ex-
ternal strabismus, diktat ion of the pupils, and painful contractions of
the right side of the face. The pulse was full, regular, and not fre-
quent; the mind was unaffected. Coma supervened, the right side of the
face became insensible, the evacuations were involuntary, speech waa
impossible, and the movements of the tongue were imperfectly pet-
formed. The pidse was feeble and frequent, and death ensued. On
post-mortem examination, a reddish serum was found to be infiltrated
between the convolutions. At the base, under the third ventricle, i
gelatiuiforra substance enveloped the commissure of the optic nervea
and the tuber cinereura. It was reddish in color, and was closely ad-
herent to the |>itmtary gland. The tubercula mammillaria were sepa-
rated by a reddish mass, which extended into the ventricle, and which j
there had the size and form of a nut.

ITie following case, cited by Gintrac * from Simon, is equally inter-
esting : 4

" A woman, thirty-tive years old. For six years accessions of pain i
in the head. Two years afterward blindness of the left eye, and thea
for two months the most intense cephalalgia, followed by loss of sights
in the right eye. Pupils still active. Anosmia, although the* pituitary^
membrane preserved its tactile sensibility. Hearing, touch, and tast<^
unimpaired. Skin warm; pulse freqneot, hard, and small. Failure ol
appetite; thirst, constipation, coma, death.

** There was congestion of the diploe and of the meninges^
arachnoid and the lateral ventricles contained senmi^ There was
grayish'white deposit, of fibrinous appearance, in the pia mater, alon^l

* G(L^t€ medicale de LifOns et nwniteur de* hnpitaut^ 1855, fi, 858*
' " Bulletia de la soci^ti anatomiQiie.'* J 860. p> li

CHRONIC CEREBRAL MENINGITIS.

241

llie ooftrse of the middle cerebral vessels, on the chiasma of the optic
iienre% the tubercula mammillaria^ and the anterior perforated spaces*
The olfactory and optic nerves were atropliied, and the chiasma was de-
fofmed. The retin® were normal* The tissue of the brain at the base
wms saperficially softened,"

Treatment. — The princijiles which have been laid down for the man-
AgcflDent of cases of chronic verticalar menin|ritis are equally applicable
to ibe basilar form of the disease. The iodide of potassium, conjoined
wilh tome one of the bromides, should be administered; and, in syphi-
litic e&8eS| the former shouhl be pushed to its extreme limit by gradu-
1% increajsbg the doses. At the same time, there are other means of
Ueatmcnt^ which are rendered necessary by the existence of paralysis,
uidUioae ordinarily consist of strychnia and some form of electricity,
Tbit details will, perhaps, be nn»re clearly shown by the citation of a
ievcmsc^ from my note-book:

A^ \V., married, aged thirty-two, consulted me, April 7, 1873, for
p«in to the head, aceontpanied by paralysis of the third nerve on the
Iftft iide, producing ptosis, external strabismus, dOatation of the pupil,
ind double vision. On examination with the ophthalmoscope, both
<>ptic papiUffi were found to be congested^ the left far more so, how-
H«r^cii&ii the right. He had had an epileptiform convulsion about
t*> weeks before coming to me, and had suffered very often from at-
Ud« of vertigo. The first evidence of tlie disease was the cephalalgia,
'*hirh had been very gradually developed during six or seven months,
^ which was mainly confined to the left temporal region. The pa-
^jm of the third nerve had been suddenly produced, on the morning
*^tb^ 1st of April, while he was eating hm breakfast.

re was not the least evidence of syphilis in this case. The af-
1 had obviously originated from long-continued anxiety of niind,
til© OQBsequence of business troubles.

I immediately began the administration of the iodide of potassium
^ llit! form of the saturated solution, in doses of ten drops three times
•^ day, increaaed to twelve drops the second day, fourteen the third,
*i*^io on. After the fourth day, the intense pain in the head began
^linish; and on the tenth day, when the patient was taking thirty
^uivalent to thirty grains— tliree times daily, it entirely disap-
ITie paralysis of the third nerve, however, continued, although
^«^ doees of the iodide were carried up to over two hundred grains
**^f, or »eventy grains at a dose* The medicine was then discon-
^***Wcd, and the patient was treated with gradually-increasing doses of
•^■Tcimia, and the interrupted primary or galvanic current applied to
^^ dosvd eye^ as nearly as possible over the internal rectus muscle
**** tJit oppfT tiytdid. This treatment was persevered with for several
^*ckji, without any marked effect upon the paralysis of the upper eye-
"d,ihrjiir-h tlf iiiffTnal rectus muscle gradually recovered its power.

DISEASES OF THE BRAIN.

and the diplopia disappeared. Nearly a year afterward, when I a^
saw the patient, the lid still drooped; but there had been no retur
the other symptoms.

A gentleman, aged about fifty, single, eonsulted me on the 1 Ith 'of
August, 1874, for intense pain in the right side of the head, withj
which he had siiffered for several months, night and day. Upon exajn«i
ination, I discovered that he had experienced an attack of iritis of the'
left eye ten years previously, and that there was other evidence of
syphilis. There was paralysis of the internal rectas of that side, whiclifll
caused strabismus, though no diplopia, as the sight of the eye had beexiS
lost by extension of the inflammation to the capsule of the lens, causing
opacity. In conversation with him, I observed that he was deaf io the
right ear, a fact which he had not noticed till his attention was called
to it and the hearing capacity tested. On examining the ear with the
speculum, I perceived that the external auditory canal was closed by a
growth of some kind, which was adherent to the anterior wall. The
ophthalmoscope revealed the existence of marked optic neuritis of the
right eye, and the patient could not read No. 3 of Galezowski. No ex-
amination could be made of th^ left eye.

On the following day, when he made his visit to me, the rigiil side
of his face was paralyzed, as was also the right side of the tongue, and
his speech was, in consequence, rendered very difficult and indistinc
I then began the administration of the iodide of potassium, in the for
of the saturated solution, starting with the dose of ten drops thrcf
times a day, and directing it to be gradually increased. This was conH
tinuod till the 14th, when I removed the growth from the ear, by ex*!
cision, with a delicate bistoury. The effect of this operation waa ai
once evident, so far as the hearing was concerned, and the patient de-^
clared that the pain in the head was decidedly mitigated. As it stillj
however, continued, I augmented the doses of the iodide by six drops i
day, instead of three, and began the application of the interruptc
primary current to the paralyzed muscles of the face and tongue. Oj
the 20th be was taking twenty -one grains three times a day. The pal
was decidedly less ; but, as there were sharp lancinating pains along 1
course of the auricular branch of the lesser occipital nerve, I made
incision through the scalp, so as to divide it. The effect was, to aboli^l
this pain altogether. The iotra-cranial pain gradually diminish^^^
under the increasing doses of the iodide, and on the 27th of August h^«^
entirely ceased. The medicine was continued for several days afte
ward, and was then omitted. The tongue gradually improved in mot^
power ; but several months subsequently was not protruded straight
although the speech was as good as ever. There has been no return
the other symptoms.

The growth removed from the ear was examined ndcroscopically by
my friends Prof. Hoosa and T. E. Clark, as well as by mva^ ftnd wfl

>li^^»

DNIC CEREBRAL MEKINGITIR

243

agreed in the opinion that it was neuromatous in character. The whole
lor was somewhat larg-or than a large pea.

The following very interesting case, which oocurred recently in my
lee, 1 quote from Dr. Lente*s excellent paper ** On the Neurotic
in of Disease," * read before the New York Neurological Society,
Deeember 7, 1874* Dr. Lente had frequent opportunities of seeing
tibn pstient in my consulting-room, and of witnessing the results of the
treAfment. Atr, W. was also kind enough to allow me to present him
tt my clinique at the Medical Department of the University of New
York, and to describe his case to the cla<is in attendance.

**The treatment of the following case I had the opportunity of
watching^ through the courtesy of Prof. Hammond, The history I had
bom the patient himself:

*• Mr. W*, a grain-inspector of Chicago, was attacked three years

igo with epileptic convulsions; has had them once a month or oftener;

tbo iome threatening cerebral symptoms; had no treatment that he

btow» of except moderate doses of bromide of potassium and chloro-

fiim inhalation. In June last he had a recurrence of cerebral symp-

Ujois, insomnia, pain, double vision, etc. This lasted two weeks, and

finppeared. On the 14th July, after some exposure to the sun, he

*M again attacked with the above symptoms, to a greater degree, and

with complete inability to raise the eyeball or upper eyelid (left eye),

*!io txtrpme Internal strabismus, diplopia, and severe cephalalgia.

iWe symptoms occurred suddenly in the night. Could neither read,

^ ♦listinguish the quality of grain. The strabismus disappeared

iL„,t„ j^^^i ^^^ ptosis also diminished somewhat, so that when he ap-

Dr, H., about the 13th of October, 1874, he could, bj/ mi efort,

'!»* lid so as to expose the cornea, but it fell back immediately;

:;tTnplom8 the same. He was put upon increasing doses of the

*'><Weo| potassium^ with the idea of relieving the hasil<tr meninffitt\

P^svmti to he the cause of the sxinptoms, the application of the

mm^ current to the brow and temple, and the hypodermic injection

hnia. No immidtale effect could be expected from the first two

«: it \<i to the last that I desire to direct attention. Prof, Ham*

r jM srd to inject the solution directly into the affected muscles,

1 ordingly did so, using gr. ^ in two drops of water; it is pre-

i that it passed into the muscle, or most likely in its immediate

l*^titnity. In all, six injections, I think, were used. I watched the

**'^ earefully and tested the eye and lid after each. They were done

^ illf^ntat^; day. He fiedared that he perceived quite a decided ef-

^^* AfttT the second there was no doubt, as I could see the change

***«ia fifteen minutes, both on the ball and on the lid, but especially

'^ the latter' after the third, the ptosis had entirely disappeared, and

* I^^fd^o^ifiBl and Mrdito^Leffoi Journal^ February, 1875, p. 82*

DISEASES OF THE BRAIK

1
I

peared, and ho could read by holding the book low. After the fifth in*
jection (gr, ^) no difTerouoe in the appearance of the eyes was diflttn'^
^isliable, and Jve could read with the book held directly before hiin.
He considered himself cured."

In this ease the iodide was carried to doses of sixty graina three
times a day, before the pain began to yield; and eighty grains, equal to
two hundred and forty grains daily, was reached, and continued for
several days, before it was deemed advisable to omit its use.

Mr. B. was sent to me, December 19, 1874, by Prof* M. A. Pallets
At the tune be was suffering from agonizing pain in the left side of the
head, paresis of the whole right side of the body, except the face, apha-
sia, of the amnesic variety inaiDly, although the power to coordinate the
muscles of articulation was greatly impaired, and from decided mental
disturbance, characterized by the existence of hallucinations and markedfl
dementia. The sight of both eyes was weakened, and examination with
the ophthalmoscope showed the existence of double optic neuritis.
There was a clear history of sy|ihilis»

I immediately began the administration of the iodide of potassiu]
in ten-graifi doses, three times a day, gradually increased, as in the fo
going cases. By the time twenty -grain doses were reached the pain i
the head had disappeared, the speech was much improved, the weakness
of the right side had diminished, and the mind was altogether stronger.
The iodide was continued up to sixty-grain doses, and then, as th<
patient was apparently cured, it was omitted, and he resumed his duti
as cashier in a bank.

Two months afterward, he had a relapse into his former condition^
The accession was sudden. He awoke in the morning with pain in th^
head, weakness of the right 8i<le, and complete loss of speech. Hi^
aphasia was removed by a single application of the galvanic curren*^^
from ten cells to the tongue, and I increased the use of the iodide as bc»-M

ore^l

lessl
?er.

rifi J^^

fore. He again recovered his hcjilth. He is now (March 23d) quite weD
It would be very easy to adduce many other cases from my private
and hospital praet ice, but the foregoing are sufficient to indicate th *
main principles of treatment in chronic basilar meningitis, Oecasioc
ally, in cases of syphilitic origin, in which the infection has been rec^n'i
it may be advisable to administer mercury in some one of its fomvi
The bichloride, in the dose of the one-sixteenth of a grain, may be give*^- n
with each dose of the iodide of potassium, or the biniodide in liV^^o
doses, in the form of pill, ^^''hethe^ the affection lias a syphilitic orig-ii*
or not, antiphlogistic measures, as they are called, are not proper* Clo-
the contrary, wine and highly-nutritious food are frequently product!"
of amelioration.

Should insomnia be present, some one of the bromides should
given, in doses of from fifteen to thirty grains, three times a daVi fill
full effect be produced.

TUBEBCULAE CEREBRAL MENINGITIS.

It may be stated that I have never observcMil any ill f'ffects follow
the adminlstrAtioa of the very large doses of the iodide of potassium
whkli I have recommended. Coryza is certainly not more apt to occur
ibAn with the small doses, nor is it more severe. Gastric irritation can
generadly be prevented by diluting each dose in a sufficient quantity of
wmter. A dose of fifty or sixty grains should never be taken in leas
tban half a tumbler of water.

In tlie treatment of the paralysis which often remains, even after all
ictive disease within the cranium has tHsappeared, electricity is almost
indispensable; and I am entirely satisfied that the hypodermic injection
«t strychnia into the paralyzed muscle, or as near as may be to it, is a
of the utmost importance. The good effects of it were very
■een in one of the cases cited.

CHAPTER X.

TUBERCULAR CBRSBRAL MSiriJIFGlTIS,

l3(FL4MMATiox of the membranes of the brain, attended with or due

to * ileposit of miliary tubercles, was for many years considered as a

'^'' ■* -* peculiar to infancy, and was known as acute hydrocephalus be-

morbid anatomy and patholog^y were clearly comprehended. It

^iM*w wtjU understood to be an affection to which adidts are liable.

By some authors, especially Ilobin and Bouchut, it is regarded as
^ being tubercular in character. It has hence occasionally been
" 1 j^mnular meningitis. Although mentioned by the ancient medi-
if«?ni, no clear and systematic description of tubercular meningitis
***» fiveo till Why tt * published his essay on the subject of dropsy of
^^^ bmin. Since that time it has received the attention of many writers
i« tkis eountry, Great Britain, France, and Germany,

SfniptOMS. — Whytt defined three periods of the disease, which he
^^*A»^ by the state of the pulse. I think the symptoms may be prep-
ay inmngod in four stages: 1, The prod roraatic stage; 3. The sta^
i foment; 3. The stage of depression; and 4. Tlie stage of reour-

i» Tub Prodrohatic Stage, — This period may be altogether want-
*%Okrinay bo so slightly manifested as not to be noticed. Generally,
■"^trer^ it is well marked.

If tie ebtld be sufficiently advanced in years, a change of disposition
^•'lUing the ftrst symptoms perceived. Thus the temper becomes irri-

**Ofc«fpimtSdna tm tlw mcwt Frequent Form of the Hydrocephalus Intemus, vix.,
rjif «r (h* Tratricles of the Brain. Warks of Robert Whyti, edited by his Son."

DISEASES OF THE BRAIK.

table^ caresses are dbregarded, and dislike is shown for those amuse*
ments which fonnerly gave pleastire. At the same time the appetite
disappears^ and the child loses flesh rapidly. Thb latter is not noticed
about the face, but is mainly confined to the abdomen and limbs* The
bowels are generally obstinately constipated, but occasionally tliere is
diarrhoea. Headache is not often complained of; neither is vomiting a
common symptom of this period. Fever is not continuous, although it
is generally present at irregular times of the day.

The prodromatic stage may last only a few days, or may be pro-
longed for two or three months,

Z* Thb Stage of Excitement. — This period is ushered in by obsti-
nate vomiting, which is present in many cases, even though no food l>©
taken. Intense pain in the head is a coincident symptom, and is so
severe that the child puts his hands to his head and cries out or awakes
screaming. Convulsions may also occur. They do not differ in gen-
eral appearance from the ordinary epileptic paj^xysms, and may be re-
peated several times.

Very early in tliis stage the fever becomes more persistent than in
the first stage, although it may still be irregular. The pulse, however,
is not hard and resisting, as in other inflammatory affections, but is soft
and compressible.

Trousseau ' has called attention to a condition of the skin present in
tubercular meningitis, which he at first regarded as peculiar to this ^s-
ease, but wliieh subsequent investigation showed was likewise found in
simple meningitis, in typhoid fever, and some other affections. If the
finger-nail be passed lightly over the surface of the abdomen or the
thorax so as to trace a series of lines, in about thirty seconds the skin
becomes red — the color being at first diffused, but very soon the lines
made by the nail are indicated by a still redder color, which persists a
long time* Trousseau calls this appearance the "cerebral stain" (tachs
ebribrah). The phenomenon be attributes to a pi^ofound modification
in the vascularixation of the skin; and, although it is not to be regarded
as absolutely pathognonionie, it is a sign of very great importance^

The intellectual faculties are not yet affected to any considerable-
ex tent, but tfie changes of character and disposition, and indifference t
things which formerly excited interest, are still well marked.

The physical strength, though lessened, \s stOl not yet so far
duced as to oblige the patient to remain in bed.

The tongue is usually coated and red at the edges, the appeui
diminished, and the bowels are obstinately constipated.

The temperature of the body is elevated, but not to an extreme de
gree; the thermometer indicating from 101"^ to 103° Fahr. Sometimes
there are distinct remissions in the violence of all the symptoms, but the
disease nevertheless goes on to its full development, Tlie transmissio]
* Op, cU., Le^oD It., "^ Fi^vre C6r6brale,"

re—

-I

sioirr^H

TUBERCCLAR CEREBRAL MENINGITIS.

second to the third stage Is ofteu marked by an amelioration
last several days.
From what has been said, it will be seen that the characteristic phe-
aena. of this stage are headache and vomiting. Its duration varies
faomi seven to foui-teeu days.

3* Stage of Depression. — Tlie pulse, which in the previous stage
ins sometimes as high as 140, and sometimes as low as 80, now becomes
kvs rapid than is normal, and may even fall below 50- At the same
tone the beat is quick, but the interval between the pulsations is at
tkiea ao great that the observer is, as Dance * says, fearful that the
lou of the heart has stopped. The interval between the pulsations is
^llkftk irregular, and this may be regarded as a sign of unfavorable im-
|K>rt,

In young infants there is a reduction in the temperature of the body
Movt the normal standard, whicli lasts throughout the whole of this
peTiocL Roger regarded this redaction, preceded as it ia by a higher
icmpiratiire, and followed during the succeeding stage by another ele-
uiion, as pathog^nomonie of tubercular meningitis.

The continued excitement of the previous stage is replaced in this by
« strong tendency to sonmolence, which alternates with a rather quiet
iMiriiim. The patient lies on his back, with the eyes lixcd, but yet not
iooldag at any object with attention. Events taking place around him
w» boger attract notice, and, tliougb when addressed in a loud tone he
ony Uun his gaze towai-d the speaker, it is very evident that the words
coiivry no idea to his mind.

Tbrt fingers are kept in almost continual motion, picking up threads
*i«l other small objects from the bedclothes, and occasionally clutching
<t imipiiary things. Again, the fingers are alternately opened and
^^i without any real or apparent motive, and again the head is turned

* '^WUy from side to side of the pillow. Convulsions are very gener-
al'/ pnsent from time to time during this stage, and may be so fre-
*i^niih repeated as to leave scarcely any interval between the seizures,
tvpu if ilie attacks do not involve the body generally, the eyes scarcely
evyf ftioape; then* being strabismus, convulsive movements of the
H% a»d constant motions of the eyeballs. The facial muscles are
w^wiw* often affected.

In the intonals of wakefulness, the cephalalgiA continues, and
Olttiei i\m peculiar scream which is so charncteristio as to have received
^ name of the ** hydrocephalic cry." It is a sound such as might be
P''*'kie©d by mingled emotions of terror and grief. Although probably
•^t««d hy the pain, it is more or less automatic, and is not exactly such

* ^ aa would be produced by unmixed physicjil suffering. It is ao-
***1»tnW» however, by that contraction of the muscles of the face in-
^'M^tire of suffering.

248 DISEASES OF THE BRAIN.

The paleness of the countenance continues, but at times there is a
sudden redness, which disappears as rapidly as it comes.

The conjunctivae are generally injected, and photophobia is present.
M. Bouchut,* who has given great attention to the subject of ophthal-
moscopy in diseases of the nervous system, finds peripapillary con-
gestion, dilatation of the retinal vessels, and deformation of the papilke.

There is often a general hyperaesthesia of the skin, for which, how-
ever, anaesthesia may be substituted. When this latter is the case the
conjunctivae participate, and inflammation results.

The limbs are weak, and, should the patient attempt to walk, the
gait is staggering. The speech is hesitating, is rarely indulged in ex-
cept in response to questions, and then with the least possible expendi-
ture of words.

The vomiting, which formed so prominent a symptom of the previous
stage, has ceased, but the constipation still persists.

The respiration is irregular, sometimes being rapid and sometimes
slow. Occasionally there are deep sighs, followed by numerous quidc
inspirations, and again the respiratory movements may be so slight as
scarcely to be perceived. This variation from the normal action, as
well as the irregularity of the heart's movements, is due to the implica-
tion of the pneumogastric nerves at their origins.

This stage may last for from two or three days to two weeks.

4. Stage of Recuerence. — The characteristic phenomena of this
stage are the return of the fever and the increase in the violence of the
symptoms indicative of cerebral disturbance. Before its onset there
may be a period of nearly complete intermission, so that the impression
may be formed that recovery is taking place. This apparent cessation
of the morbid action, how^ever, only serves, with the experienced ob-
server, to make the reappearance of the symptoms more striking.

Convulsions are more frequent and violent than in the previous
stage, and tonic contractions of the limbs are not uncommon. These
contractions arc more generally met with in the muscles of the neok
• and upper extremities, and vary from time to time in their intensity.
The head is thus thrown backward, and, as the morbid action frequently
extends to the muscles of the back, an appearance in the patient not^
unlike that present in tetanus is produced.

Paralysis eventually supervenes. At first this is incomplete, affect—
ing only a single limb or the muscles of the face, but it extends, andL
both limbs on one side, or an arm and a leg of opposite sides, become in-
volved. Voluntary power is lost, but reflex movements can be exoit6<9-
by pinching or tickling.

The delirium acquires increased intensity, and alternates with ihe^
somnolence, which likewise becomes more profound, and which gradu^ —

^ " Du diagnostic des maladies du systfimo nerveux par rophthalmoscopie,*' Parted ^
1866, p. 45, c( seq. Plates iv., v., vi., vii., viii., ix., and xl, of the Atlas.

TDBKRCULAR CEREBRAL MENINGITIS.

949

' nsa^ks all the oth^^r symptoms, till at last the coma is persistent
and general, and spinal sensibUity is lost.

Before death the pulse rises iti frequency, a cold sweat makes its ap-
p, and the patient dies either by a slow procesa of a^phyjcta, or
ilaions.
F'Thc fact that tubercular meningitis is not confined to infants is now
erally admitted. Dance * was the first to recognize its occurrence in
■didtii, and Gerhartl/ of Philadelphia, a few years subsequently reported
ftcYend cases. Ledibuder ' also pointed out tlie analogy between the
tobereular meningitis of infants and that of adults, and still later Val-
Ubt* gsiTVf the weight of bis authority to the same oflTect.

So far as the symptoms are concerned, I have never been able to
lurrcuire any essential points of difference between the tubercular men-
iogitifl of children and that of aflults.

The affection is, of course, moditied, as are all other diseases^ by the
W of the patient, but, when allowance is made for tins factor, the
' ' oess ia one and the same in character. In adults, however,
y supervenes in the course of tuberculosis of the lungs,
wiifiTJn^ in infants it is ordinarily a primary manifestation of the tuber-
cular diathesis.

Causes. — Tubercular meningitis is an expression of a general state
I i!i< §y*^tem. To enter at length into the question of its etiology
«" 'liil necessarily involve a discussion of the cause of the diathesis to
Hick it is essentially due. Nevertheless, there are a number of detor-
Quning^ causes that may be appropriately considered. Age is an im-
I^Unt factor in determining the accession of tubercular meningitis,
h is mnt during the first year of infancy, but is more common during
^ pifrioil extending from the second to the seventh year than any
uther time of life. From eight to ton it is much less frequent, and from
**n to £fieen is rarely seen.

h ubdts it is most common between the ages of seventeen and
*™t?. From thirty to forty it is rare, and after forty is scarcely ever
nmiritt

Malw are more frequently the subjects of tubercular meningitis than
***»le!i, and this holds good for all ages of life.
'Hi© iteason of the year appears to exercise no influence,
Ai t5 many other exciting causes alleged by authors, such as blows,
•*^iouai excitement, and previous diseases, nothing very definite is
™J*n* The same cannot, however, be said of the morbific inlluence of
*d itr, insti6lolent food, improper clothing, neglect of cleanliness, and
> wegtiti of other sanitary requirements*

Utt

-DtU

' Ameruyin Jourmil of the Jfidiml SettnteA^ 18ii4.
' VsHbetioD tuberculeuso aigtio Ue li pk'-m^re/* Paris, 1887.
iteingHe t«bercaleim ctiez I'adulL'' Arckiii^ g4nif«iu d$

midteim^

250

DISEASES OF TBE BRAIK.

Diagnosis. — Tubercular meningitis is liable to be confounded with
seveml other affections, and can sometLmes only be distinguished with
difficulty.

From simple meningitis it may be diagnosticated by the facts that
the onset of the former is sudden, while the latter h insidious in its ap-
proach, and slow in the development of its symptoms; the one goes on
steadily through its course, the other halts and remits; in the one the
temperature of the body rises several degrees, in the other the elev^adoa
is scarcely ever more than two degrees; in the one there is no hercditafy
tendency, while in the other inquiry will usually reveal the existence of
hereditary tubercular predisposition.

The mental symptoms show a marked difference. In simple menin- _
gitis the delirium is often furious, and is always very active; in tfae fl
tubercular form of the disease the delirium is quiet, and alternates with
stupor.

In typhoid fever there may be vomiting and headache| but the
bowels are not constipated, and there is tenderness over the right hypo-
gastric region. Moreover, the epistaxis, the eruption, and the swelling
of the spleen, which occur in typhoid fever, will aid in making the diag^
nosis more certain^

Worms in the alimentary canal may give rise to a set of syuiptonis
very similar to those which form the prodromata of tubercular menin-
gitis. As Jaccoud observes, therefore, it is well, whenever a chUd ex-
hibits these symptoms, to administer one or two doses of a strong ver^
mlfuge,

A peculiar affection, to which young infants are liable, may be mis-
taken for tubercular meningitis. It was first described by Dr. Gooeh»*
but derived its name — " hydrocephaloid disease " — from Dr. Marshall
HalL I have already alluded to this disorder under the head of cerebfal
aniemia. In it the child is irritable, restless, starting at every noise,
moving in sleep, and often waking screaming, A^omiting is frequentljr
present, but the bowels are loose* The whole appearance of the child
betokens exhaustion, and, if due care be not taken, death may ensue.
The absence of constipation, the history of the case, and tlie depressed
state of the fontanelle, if this be yet open, will suffice to render the
diagnosb clear.

Trousseau considers the irregularity of the respiration the most im
portant sign indicating the presence of tubercular meningitis. '* In
other disease," he says, **will you meet with this singular anomaly,
You will not observe this unequal and irregidar respiration either in tl
essential convulsions of infancy or in typhoid fever. I have reason ^i^
then, for insisting on the importance of the symptoms.''

Prognosis, — ^There is not much to say under this head. The ordi

* " On Some Smptoms in Clilldrcn erroinjoush ottributod to Congcfltioo of tbe Bniia.
Goot'li'fi Essay d, New SjdenhiUD Society, 1859, p. It9, .

im-

noSJ

miL' W

T0BEROULAK CEREBRAL MENINGITIS.

251

►tion of tlie disease is death. I have never seen a case re-
and, though instances with a favorable result have been reported,
I am disposed to think the diagnosis of such has been erroneous. Drs,
ll»igs and Pepper/ of thirty-one cases, had no recovery, though they
ivpori a case of tuberculosis of the meninges — not tubercular menin-
in which recover^' appears to have taken place, though the chUd
died a year or two afterward with dysenter)'.

It seems cotitrary to reason to expect a radical cure In a disease iii
irliieb the cause cannot be removed. Do what we will, the tubercular
ikpoatt remains; and, as Jaecoud remarks, the reported cases of recov-
tryw^re rather instances of a long remission in the intensity of the
•jiDptaiiis. Seitz,* in his recent treatise, asserts that the time when cases
o! arute hydrocephalus were cured has gone by, and that former ap*
pveat success is to be attributed to false diagnosis. He declares that
1» h»A never witnessed a case terminate favorably.

Morbid Anatoniy and Pathology, — A question arises at the outset of

%h ' ' tH^ative to the morbid anatomy of tubercular meningitis,
•tu > to the essential character of the disease; and that is^

whether the ^niy semi-transparent gnLnulatious met with on post-
mof!t»m examination are tubercles, or whether they arc an entirely dia-
tiacl morbid product? Valleix, Rilliet and Barthex, Barrier, Grisolle,
VliiB iiiid Pepper, and others, regard them as tubercles. GrisoUe ex-
ptna biiuself clearly on this point. " Wc have no doubt," he says,
**thtt these granulations are tubercles in a rudimentary state; for we
hft many times, in the same subject, followed tlie morbid product in
iti different phases of evolution from the amorphous condition to the
Mj-deieloped tubercle/'

(k the other hand, Bouchut, basing his conclusions mainly on the
mictoicopical observations of liobin, is of the opinion that the granuJa-
tkniiM fomied: 1. Of tibro-plastlc elements, consisting of free Quolei
iod btvfdrm cellS) and ovoid cells. The nuclei are ovoid or spherical,
^ftignwimlly T^ry smali, not exceeding 0*008 to 0.009 in. in diameter.
tOi% gr^t quantity of granular amorphous homogeneous matter,
*Uch keeps the other elements strongly united. 3. Of a few vessels
*ttd iibm of connective tissue. Among all these elements the tuberou-
^^orptuclea of niicrographers are not to be found; and^ therefore, the
'•■W6 cmnooi be regarded as tubercular in character. M. Empis' also
^Btlfodi that the microscopical analysis shows that the gray granula-
™* ».Te t»ntirely distinct from tubercle. On the other hand, it is
""^f^d— Mid I am disposed to think with force — that the most which
^ inr^itigations of M. Kobin and others in accord with !um show, is,

'^i l*Vmnleal Treatise on the Diseased of ChildFen,'' PUit&ddpbm, 1670, p. 452.
^Ut ItcEungiiU TubensnloM der Ertrachsenen.^^ Berlin, 18T5| p. 877.
'"^^Ua de 1* granulk,'* Paris. 1865.

DISEASES OF THE BRAIX.

that there is no special characteristic of tubercle which will enable
declare with certainty that it is present, and that it does not possess a
structure which is the same in all stages of its development. The col-
lateral evidence goes very far to support the view that the granulationa
are tubercular in character.

The question which also arisc3s, as to whether the inihjramation pre-
cedes the tubercular deposit, or vice versa^ is generally decided in favor
of the prior appearance of the tubercles* The granulations are met with
in the cuurse of the vessels of the pia mater. This membrane is always
more or less inflamed, and is thickened by the infiltration of sang^xiine-
ouSj serouSj plastic, or purulent exudations. The granular or tubercular
matter is generally deposited at the base of the brain, and in this posit ioa
is doubtless the cause of the derangonients of motility which constitute
so prominent a feature of the disease. Its ordinary seat is along the
course of the middle memngcal artery and its branches. Sometimes^
though rarely, it is found on the convexity of the brain.

The tissue of the brain is not generally much involved, although on
section the red points, indicative of the situation of blood-vessels, are
very much increased in number. Occasionally there arc small extmTa-
sattotis of blood found in the gray substance.

The ventricles are distended by serum, and this is sometimes so gretii
in quantity as to cause the rupture of the septum lucidum. The liquid
is either clear and limpid, milky from the presence of pus-globule«, or
bloody from containing red corpuscles.

The morbid anatomy of the lungs and other organs, although ini^r* '
esting in the present connection, need not be dwelt upon; suffice it to
say that tubercular deposits are always met with in some one or more
of the viscera and especially in the lungs.

Treatment.— In regard to a disease so uniformly fatal as tubercular
meningitis, there is not much to say. The principal advice I have to
give is, to refrain from blisters, antimonial ointment, leeches, and drastic
purgatives, which have no other effect than to shorten the life of the
patient, and to make his existence still more intolerable than it is mada
by disease. Iodide of potassium does less harm, but I have never
known it do any good. Niemeyer, however, recommends it, and manj
will doubtless continue to employ it on his authority. Seitz,* in a work
of nearly four hundred pages, treating of tubercular meningitis in
adults, devotes less than two pages to the subject of treatment^ and
speaks rather flippantly of all supposed remedial measures.

When we have any reason to suspect an hereditary tendency to
tubercular meningitis, prophylactic measures may be used with hope of
success. These consist in providing for pure air, ample clothing, nutri*
tious food, and in the administration of cod-liver oil, iron, iodine^ and^

* Op, €t he. dt

SUPPCRATITE EXCEPUALITIS OR CEREBRITIS,

253

A climate not subject to sudden vicissitudes, and of s^ich a
?f as regards wannth and dryness that the patient can spend a
%t portion of the day in the open air, ia also a matter of prime im*

CHAPTER XI.

$irpprRATtvs kxcepualitis or cerebritis.

PUEATivji inflammation of the brain is a %ery rare affection un-
[ilicated with meningitis. In this latter connection it has already
t sufHciently considered. In the present chapter, therefore, I shaU
\ it scDlely as an independent lesion, and mainly in reference to the
mbeequont formation of abscess.

SjUptoms, — Tlie symptoms of suj>pnrative infiamniation of the brain
my according to the seat of the lesion^ and are rarely of such a charac-
ttr u to enable us to say, with any great degree of certainty^ that we
bcTt a case of uncomplicated encephalitis before us. Nevertheless, cer-
tiitt pbonomena Imve been recognized, and, after deatli, the evidenoea
of inflammation of the brain have been discovered. But these symp-
tometrei, many of them, met with in other cerebral disorders, and there-
loftainoot be regarded as pathognomonic. It is difhcult, if not impos-
Afe, to arrange them in stages; and therefore, after the prodromata, I
Aillooimder the ph»jnomena of acute encephalitis in accordance with
tfcii relation to the several functions of the organism liable to be
effected.

TH^ premonitory symptoms are similar to those of cerebral con-

. and doubtless depend upon a like pathological condition. Thus

' *f« vertigo, pain in the head, noises in the ears, trouHesof vision,

tttHttLtifM, and diiheultiea of speech. They never, however, last as long

*• tKty do in simjile congestion.

Sometimes the tirst-ob served symptom of approaching encephalitis is
^ ^leptiform convulsion,

fe the ftiUy-established disease the phenomena are very decided, but
** tb« dame time have no necessary or constant relation with the pa-
*Wogy, as similar symptoms are met with in other very different affec-
tSom

biiorcUri of SensihtlUy, — At first, there h generally hypersestbeaia;
**l*ie«lB!*ntly, amrsthesia. Heatlache is a common symptom, as it is in
•* o»ti»y other cerebral diseases. There is no particular location of the
'•^'^"'-•oiiietimefl the frontal region, at othera the occipital, and again
*** Hrtictl or parietal regions, being its seat. It varies, likewise, aa
**^R*rti intensity and form, and may consist of a feeling of fullness or

S54

3E8 OF THE BRAIX.

constriction only. It is present from the very beginning of the disease,
and usually continues through its whole course.

Pains are felt in various parts of the body, are sharp and lancinating,
and often attended with cramps. Cutaneous hypenesthesia is also oc5-
casionally met witlu

In the next place, there is amesthesia, with all its accampaniinents
of formication, numbness, and other abnormal sensations of the kinii^
mainly affecting the face and upper extremities. As to the special
senses, the sight is almost always deranged. There are bright Hashes of
light, iridescent appearances, and photophobia, all showing increaS4?d
irritability of the retina. The pupils are contracted, the conjunctivae
suffused, and the eyeballs are the seat of a dull, aching pain. Subse-
quently; the pupils become dilated, and vision is lost. Ophthalmoacopie
examination shows, in the early stages, jiapillary infiltration, with retiiial
congestion, and later, papillary atrophy and granular degeneration, the
results of optic neuritis. There is also, generally, double vision, to
whicli allusion will be more fully made directly.

The hearing is at first very acute, and even slight noises are more or
less painfuL Noises in the ears, of various kinds, are present. As the
disease advances, the hearing becomes much impaired, and is gradually
lost, in one or both ears.

The taste and smell are rarely affected.

Disorders of Motility. — As with the sensibility, the motor organs of
the body at first exhibit evidences of increased excitability. Thus,'thew
arc twitchmgs of the muscles, mainly of those of the face, and clonic or
tonic spasms. Sometimes these last for several days, Subsultus is
especially noticed in the flexor tendons of the wrist.

General convulsions may t^ike place, with or without loss of con^
sciousness. Frequently the action is limited to one side of the body, W
implicates one side of the face, or a single limb. Strabismus oecui%
and double vision is produced, at this stage, from spasms of one of th6
ocular musc^les.

This period of muscular excitation corresponds very accurately wil
the stage of augmented sensibility.

It is succeeded by a period of iliminished motor power, Paraly
generally begins in a distant part of the body, and slowly involves one
side. Thus, there may at first be a difficulty in raising the toes, or in
grasping things with the fingers; then the knee becomes weak,
flexors of the thigh follow, and the whole Umb drags. If the arm be
first member affected, the difficulty advances from the fingers to
elbow, and thence to the shnulder. Sometimes the morbid action ex
tends equally on both sides of the body, and then the gait becomes
weak and shuffling. Tho legs are spread wide apart, so as to increaaei
the base, and keep the centre of gra%^ty more easily within it. The
knees are bent, the pelvis is flexed on the thighs, and the whole h<xlv is

tliflfl

SUPPURATIVE ENCEPHALITIS OR CEREBRITIS,

255

tncKned forward. The face rarely escapes. It may be affected on one
dde only, in which case there is distortion, or there may be a gradual
^ore of muscular power on both sides. The muscles connected with
IIm eye» almost always suffer. Ptosis is common, and external strabis*
Qnti^ causing' double %*ision, accompanies it, both being produced by the
kiplication of the third or motor oculi nerve.

One side of the face sometimes becomes f^emianently contracted,

i Ibua an apj>earance is produced somewhat resembling that which is

aus^Mi by paralysis of the ojiposite side. It may be distinguished from

tbia latter condition, however, by the fact that in it the eyelids are spas-

oio^cally closed, and the side of the face much more distorted than

lit ^ is paralysis of the opposite side, Tlie tongue is always, in

iiy uce, prominently affected. The first sign of diminished mo-

IflUf ia the frequency with w hich it is bitten, in conversation or masti-

Qition, and sometimes it is made quite sore, on. one or both sides, or at

\hf! tip, from this cause. Then tlie patient discovers that long-contiimed

ipeaking causes a sensation of fatigue, at tlie root of the tongue, and

thit a feeling as if tliis organ were tco large for the mouth is expe-

Hfnce*! Then articulation becomes indistinct, the words are clipped or

I over, so that at times it is difficult for others to understand what

bUorder^ of Intelligent^, — ^The first indication of mental weakness
*» the fluaceptibility experienced to the influence of emotions^ The
pilk'nt will thus get uncontrollable fits of laughing or crying from very
•light causes, and sometimes from no apparent cause. These paroxysms
*^ fi^qucntly of mixed character, the patient passing from laughing to
**7^ng^ and vke mrsa^

Tho memory begins to fail at a r^ry early period, especially ag re-
^i^ the names cf things. The enfeeblement is by no means, however,
^^afined to words, but facts and circumstances likewise fail to be remem-
^^> Gradually a condition of complete dementia ensues, and finally
'^fti^ with or without previous or alternating delirium.

DUorders of the Jn/nciionjt of Organic Life, — Tliere is always
*^"Hle excitement in encephalitis. At first the pulse is frequent, rising
^ 1^, but as the disease advances it fulls, till toward the close it go«8
"*«ow tho normal standard. It is characterized, according to Barras,'
V % characteristic tremulousncss {tttimblotUment)^ which he compares
^ till* imequai Tibrations of a cord moderately stretchetl. This pecu-
'•'Hy he attributes to irregular arterial dilatation. According to my
•^|K>rifrnoc, the symptom is by no means constantly met with, and it
^'^inly is not pathognomonic, for the same peculiarity of pulse is
"'•^^id in several other disorders. In a case, however, now under my
^^■^1 in which there is reason to suspect encephalitis and abscess, the
Dt^nnn is present in a marked degree, not only in the radial
^ "* BoUeliii de U ioctit^ rnddicale d'Imulatfcm/' Juin et 0<^bre, 19S8.

256

DISEASES OF THE BRAIN,

artery, but in the temporal and the angular, as it passes between the
nose and the inner angle of the orbit.

The respiration in the lirst stages is not materially deranged, but
later it becomes irregular and stertorous, and hnally asphyxia niay take
plaoe.

The temperature of the bod^^ is elevated till the fever abates, and
paralysis makes its appearance. The thermometer rarely, however,
goes above 103° Fahr.j and is generally a degree below this point*

The digestive organs usually show more or less evidence of derange-
ment* Constipation is always a prominent feature, and the appetite
is capricious* At times the patient refuses to eat, at others he will
cram his stomach with all kinds of edibles* Deglutition is often troub*
lesome, and occasionally dangerous, from paralysis of the pharyngeal
muscles. Cases are on record in which death has occurred by the food
becoming impacted in the throat, and several cases have come under my
own notice, in which^ from a like cause, a fat^l result was barely pre-
vented by the use of very energetic measures.

Moreover, the secretions of the mouth are almost always altered
either in quantity or quality, or both, and the sensibility of the tongue
and faucial mucous membrane is often impaired. Hence, the patient is
not aware that he has iilled his mouth, and goes on cramming it witli
food, which makes an alimentary mass larger than can pass through
the oesophagus. This, of course, even without the phar}mgcal paralysis^
interferes with the act of swallowing. The fasces are sometimes passed
involuntarily, but this is almost entirely a feature of the last stage*
Nausea and vomiting are present more or less from the very first*

There may be either retention of urine from paralysis of the bladder,
or incontinence from paralysis of the sphincter. Or both conditions
may coexist, giving rise to a constant dribbling.

These symptoms may be arranged in five classes, designated by the
most prominent feature of each: the paralt/tie^ the comatose^ the tpi-
lepti/orm, the a podded if orm^ and the maniacal.

Complications may and often do arise. Tlius there may be menln*
gitis, temporary congestions, extravasation of blood, effusion of serum,
or some intercurrent visceral affection.

The tendency of acute encephalitis is to suppuration and the conse-
quent formation of abscess, and many of the symptoms enumerated are
due to the supervention of this condition. Death ensues gradually
from exhaustion or asphyxia, or may take place suddenly from tlie
bursting of the abscess into the ventricles, or upon the surface of the
brain.

Causes. — No age is exempt from the disease, although it is more
common in old persons than in adults of middle age or young persons.

It is probably more frequent in males than females solely from the
fact that they are more subject to the exciting causes of the disease.

SUPPURATIVE ENCEPnALITIS OR CEREBRITIS.

351

r these are the ioortlinate use of alcoholic liquors, vonereol ex-
Bxtreme intellectual exertion, great emotional disturbance, and
ttspoiiire to extreme heat.

It may also be induced by disease of the iuternal ear, by erysipelas
afflicting the heaul, or by severe attacks of scarlet fever, small-pox^ or
ollber eruptive disease*

most common cause, however^ is injury of the brain.

\, — Tim diagnosis of suppurative encephalitis is, in the first
flifficalt if not impossible; the symptoms being" common, as I
already said, to several other disorders. From cerebral hirmor-
riMge Ibe distinction can be made without difficulty, for, although en-
OTptialttis may bo developed with rapidity and by an apoplectic seizure,
tl»t9»dency is for the subsequent phenomena to become progressively
mom marked, while in haemorrhage there Is a gradual amelioration.
TbiB pulse in ha?morrhage is from the first slow and regidar, unless the
I ttiedulla oblongata be the seat, while in encephalitis it is rapid and ir-
t«gaUr.

ItiHungitis is always associated with superlicial encephalitis, and
hoatit the symptoms bear a certain amount of resemblance to those of
till* *■ I under consideration. But the latter is, in general, chanic-

l^r iM? facts that the paralysis is more defined, both in intensity

iodloeation; thai the delirium is less acute; that the cephalalgia is not
•o intense, nor the delirium so prominent or constant a phenomenon.

In epilepsy the paroxysm is the main phenomenon of the disease,
Wkca this ceases, the patient in general recovers his ordinary mental
^*niltir», but the epileptiform seizures of suppurative encephalitis are
torrw loUowed by complete intellectual restoration,

nse with which it is most likely to be confounded is that
^^ : it^s obvious characteristics, is clonominated general paralysis.

i iojow (d no diagnostic marks between the two conditions, except that
g*'^<'nil paralysis is usually of longer duration, and is ordinarily charac*
t*-n^ hy a peculiar form of mental aberration — the deiire des tjran-
<^«fri of the French.

Tbt ivmptoms due to tumors are often almost identical iu character
*ila \how attendant on abscess. The history of the case is our only
•'*fnidi% The fact that the brain has received an injury of some kind
™tnclicate suppurative encephHlitis as the probable difficulty. A lady
^ «t tb« moment of writing this, under my charge, who has been auc*
*^»»'Iv txeaUHl by several of the most skillful diagnosticians of this
^Jt *t times for abscCM, and again for tumor, and I venture to sa\* that
•» one, trtthout th© aid of a post-mortem examination, can say nvhich
lnioaexiy|0,

^MlgMEli, — Suppurative encephalitis is invariably fatal, if the dis-
•■••Joitliot terminate in resolutitm. As Jaccoud, however, remarks,
•'■'■^t alkg«d cure before the stage of suppuration is reached must
17

DISEASES OF THE BRAIK.

always have an element of uncertainty about them, and do not there-
fore permit us to mitigate the unfavorable character of the prognosis.
Drs. Gull and Sutton,* while stating that there is nothing in the morbid
anatomy of cerebral abscess which makes it necessarily an incurable
affection, admit that practically it is irremediable. In this opinion I
unhesitatingly concur.

Morbid Anatomy and Pathology. — Suppurative encephalitis is a local
disease restricted in its action, and hence affecting a limited and well-
defined region of the cerebral tissue. This may vary from the size of a
walnut to that of the closed fist, and is ordinarily irregularly spherical
in shape. Although never of a diffused character, there may be, at the
same time, several centres of inflammation. The part most frequently
affected is the gray matter of the cerebrum — the morbid process in-
volving the white substance in its progress. Next, the cerebellum ap-
pears to be a favorite seat. The corpora striata, and the optic thalamic
are also frequently involved.

It sometimes happens that the pus which results from the inflamma-
tory action is not collected in a cavity, but is infiltrated into the sub-
jacent tissue. In such cases there is no well-defined abscess, but a
pulpy mass is found on examination after death, consisting of the ele-
ments of the brain-substance in a more or less disorganized condition,
with those of the blood intermingled with pus — ^the whole of a greenish-
yellow color.

Again, there may be a collection of pus, but at the same time the
walls are imperfectly formed, and there is infiltration to some extent.
Lastly, the puriform deposit is entirely limited by a membrane consist-
ing of connective tissue, and forming a cyst. The cerebral substance in
contact with the walls of an abscess gradually breaks down, and hence
the cavity undergoes constant enlargement in all directions, but espe-
cially in the lines of least resistance. If the abscess is near the suifaoe
of the hemisphere, the tendency is to enlarge toward the external
periphery ; if it is situated in the central part, in the corpora striata or
optic thalami, the absorption of the peripheral tissue takes place in tli&
direction of the ventricles. In the first instance, when the rupture en.—
sues, the pus will be extravasated into the cavity of the arachnoid; ija
the second, it will be poured out into the ventricular cavities. In eitla^r
case, coma and death will result if the amount of pus be su0icienfc.l^^
large. It has happened that the pus has escaped from the cranium t>^
the nose or ear. A lady now under my charge experienced this pesmml'
several weeks since; a large quantity of purulent matter making i"^-
exit through the posterior nares. She is still alive, in full possessioo. ^^
her reasoning faculties, and her articulation perfect, but with the lo^
of sight in both eyes, paralysis of the right side of the face, the 1^^
arm, and leg, and suffering the most intense and constant pain in 1^ ^
* '* Abecess of the Brain," Reynolds's "System of Medicine,*' toL IL, p. 544.

SUFPtTRATITE EKCEPHALITIS OR CERHBRITIS.

250

Tlie seat of the lesion is probably partly in the right half of the
^ Vafolii, The suppurative action is doubtless stLll going on, and I
regmrd Iter death as inevitable.*

The »ubstaiice of the brain in contiguity with the abscess, as already
undergoes disintegration. This is in the nature of softening.

CnRONIC CEREBRAL ABSCESS,

Suppurative inflammation of the brain, terminating in the fonnation
of abscess, may be of a chronic character, the course of the disease ex-
titiidtti^ over several months. This is especially apt to result from dis-
eide of die internal ear.

Cftses have been reported by Abcrcrambie,' Lallemand,* Toynbee,*
Rrtridre,* and others, and three have come under my own observation.
y* Chronic abscess may also result from injuries of the brain or skuU,
from suppuration set up around a clot duo to extravasation of

Am in the acute form of the disease, there are no very characteristic
oms indicating the fonnation of abscess. Indeed, in some cases
are no symptoms at all referable to the brain for the whole period
of the course of the disease, till a short time before death* A great
I«rtof a lobe may be destroyed, and even both anterior lobes almost
^lotiith ted, and the patient continue to manifest his ordinary

ii^l^ i^nce.

Ribi^je* has oollected a number of interesting cases, several of
▼ludi timost overturn some of our most definite ideas of cerebral physi-
<*^3rind pathology. Thus, he cites (Observation II,) the case of a
nati who entered the Hdpital do la Piti6, January 27, 1866. The pa-
tieot iria depressed, answered questions with difficulty, and complained
^ t violmt pain in the head. The symptoms were supposed to indi*
**^ the existence of typhoid fever. Two days subsequently a purulent
***chMge was noticed from the right car, and, the pain in t\w head per-
gi thff diagnosis was changed to suppurative otitis, with probable
••"lii of thi? prtrous portion of the tern pond bone. Leeches were ap-
Vi%i behind the ears and purgatives administered, after which the

* Ihii pftdccit died fibortly aSier the foreigoing lines were written. She grftduiillj pasted

t of profound comji, in which etuti? deiith occurre<L The pus continued to b«

I in •mfttl qunntUy tip ta the l&^t^ and micro^copccul e&amtnation dUcIoscMl tliu

t of [guiglioii^cctls contaitiing granular mnttt'r, oiI-g1obuU>s^ and other reniainij of

I aerrous li^tio. No po«t-niort«m ciAminittion couhl be obtained,

^ "* Ott Cliro&io IntUmm«tion of the limn snd its Membranes/* Edinb^r^k Mtdieal

.^ur-ti.-.,J J^rnai^ val x?!., 1 8 IB, p. 263, tt se^,

iuMst^m of Uie Kar/* cttv, PhtUdtlpMa, 186a
^*Pm abcvf dt Vmc4\ihii\e coos^cuiifa k la cari« do rocfa«r,** Tb^se de TuH,

260 DISEASES OF THE BRAIN.

patient felt so far well that he determined to leave the hospital. He
went to work again, and, on the 12th of February, attended a ball.
The following morning, pus, mixed with blood, was discharged from
the right ear, and, the tendency to stupor reappearing, he again
presented himself at the hospital. It was then ascertained that the
flow from the ear had begun several years previously, but had ceased
for the two years immediately preceding his first entrance into the
hospital.

On the 14th he was in a state of not very intense stupor, since he
was able to complain of the pain in the head; his pulse was 60, full and
hard, and pus was passing from the right auditory canal. By the 16th
of February the stupor had increased. There was no paralysis, devi-
ation of the face, nor alterations of sensibility. The patient under-
stood questions put to him, but answered slowly and imperfectly. The
eyelids were closed, light appeared to be unpleasant, and the purulent
flow still continued. He died at nine o'clock that night, without con-
vulsions.

The post-mortem examination of the head revealed the following
condition:

The external auditory canal was filled with desiccated purulent mat-
ter; there was neither abscess nor abnormal redness about the ear.

The superior longitudinal sinus was gorged with blood, the veins
were black and dilated; the brain appeared congested, but a yellow
tint of the right cerebral lobe was noticed. At the inferior face of this
lobe, where a rupture had occurred in handling the brain, a quantity of
pus estimated at one hundred grammes (about three ounces) flowed
out. This was of a greenish color, and of offensive odor. The cavity
left was about the size of a hen's efrg^ and was bounded by red, indu-
rated, and thick walls. The pus, which during life had flowed from the
auditory canal, had not come from the abscess, but from the carious
petrous portion of the temporal bone.

Around the abscess the substance of the brain was yellow and soft-
ened. Three-fourths of the middle and posterior lobes were inflltrated
with pus and softened in texture. The capillaries were not visible to
the naked eye ; the convolutions of the island of Reil were not recog-
nizable, and the neighboring convolutions were not now distinct. ITie
corpus striatum of the right side was healthy in its anterior fourth. In
the rest of its extent it was softened. The optic thalamus was also
softened, as were likewise the roots of the optic nerve. We see that,
in this case, as Ribi^re remarks, a considerable abscess had destroyed, in
great part, the corpus striatum and optic thalamus, and that, neverthe-
less, the patient had been able to work till within a few days of his
death, and was so slightly paralyzed as to be able to attend a public
ball. Aside from a certain hebetude, the intellectual faculties were not
deranged.

SCPrrRATITE ENCEPHALITIS OR CEREBRITIS.

261

}tlier patient observed by Ribiere presented an entire iibsence
ibral troubles, no paralysis, no contractions, no convulsions; the
ittMbtltty WM intact, antl the intelligence was active. Nevertheless,
ibera wma a degree of stupidity expressed in the coiinteQance, and the
ei|ir»88ion was dull. Still there is almost always some pain in the head,
wbich may be irregular as reg^ards its location and character, or may
b« oonEned to one particular spot.

In one of the cases under ray observation, there was very acute pain,
aboost cTonstant nausea or vomiting, a strong tendency to coma, and
bemtpleg-ia of the left side, coexisting with purulent discharge from the
riglit e^r. The patient, who had a short time previous suffered an attack
of acarict fever to which the ear-trouble was due, died suddenly, coraa-
tom^ but without convulsion. ExaminatioTi after death showed the
atisieace of caries of the petrous portion of the temporal bone, and an
ilMoeai containing about two ounces of pus in the middle lobe of the
li^t hemisphere. The right corpus striatum was softened in about
baU of its extent*

In the other case there had been profuse discharge from the right

•ar for several yearsi unattended by any cerebral symptoms except

ooeatiooal pain and headache, which were supposed by the family to be

Aift to gastric derangement, and for which no medical advice w*as ever

aiked. One morning the patient, a young lady, twenty years of age,

WW itiddenly roused from bod by an alarm of fire. In her hurry to

dras herself, and in the confusion of the moment, she struck her head

»l5tin«t the edge of an open d^tor. She immediately felt a severe pain

to tike head and cried out, but almost instantly sank down to the floor

ia I stupor, from which she never emerged, death ensuing within five

houn. Da removing the calvariuni a large extravasation of pus was

diioovered under the arachnoid, covering the right hemisphere, and it

^u l&oertained thitt an abscess, the cavity of which was as large as a

«®»B <}«ange, had occupied the middle lobe, and had burst through the

®<«W«« superior surface by rupturing the cerebral substance. The

P«*l0iis portion of the temporal bone of that side was carious, and com-

■OBicitcd by several very small openings with the abscess-

Whea speaking of cerebral bsemorrhage, I have referred to another
cur la which there w^as abscess of the cerebellum, produced by injury
^ iKe ftkuil. In this instance there were notable symptoms, vertigo,
*^tttlaiotia^ nausea, vomiting, and violent pain in the back of the head.
M ini there was no paralysis, but the patient subsequently became
P^'S^ttgic, and died in convubians. Examination after death disclosed
•"•thsccitti, the cavity of which comprehended nearly the whole of the
H lob(! of the cerebtdlum.

Pmf, RooHa,* while expressing the opinion that a suppurative pro-

'*X Pvmctkal TrcmtiM oa Dbcu^cii of the Ear^ mduding tbe Aattomv of the OrgftU,**
**» twk, WUliam Wood k Co., IStM, p. 44Q.

262 DISEASES OF THE BRAIN.

cess of the ear is probably necessary for the production of an abscess
of the brain, reports a case which leads him to suspect that there may
be such a thing as a chronic cerebral abscess leading to disturbing aural
symptoms, such as tinnitus aurium, and pain in one side of the head,
without any primary aural aflfection. He treated a gentleman, of about
twenty-nine years of age, for some months for such symptoms as have
been indicated, and when he died a cerebral abscess was found. He
could hear the watch for but three inches from the left ear, which was
the affected one, and the drum membrane was sunken. Prof. Roosa
supposed the case to be one of chronic proliferous inflammation of the
middle ear. The patient got no relief; he became very despondent on
account of his tinnitus aurium, and gave up his business and died at Sag
Harbor, Long Island, of malignant pustule, about two years and a half
after Prof. Roosa first saw him, and three years and a half after his first
aural symptoms.

Dr. George A. Sterling made a post-mortem examination, and
found great injection of the pia mater over the petrous portion of the
temporal bone, and an abscess about the size of a ten-cent-piece in the
brain-substance. It was bounded by inflammatory adhesions, and con-
tained about ten drops of pus. The abscess was situated on the left
side, in the superior lobe, one inch from the median line, and two
inches from the coronal suture. In this case there had never been a
suppurative inflammation of the ear.

The fact that abscess of the brain may occur without being preceded
or accompanied by suppuration of the ear is beyond doubt.

Although recovery from chronic abscess of the brain never takes
place, yet life is often prolonged for several years, even when there may
be marked symptoms of cerebral disorder. And when death occurs it is
generally suddenly, with or without obvious exciting cause.

Treatment. — ^The treatment of acute suppurative encephalitis is alto-
gether palliative. Symptoms, such as pain, vertigo, and vomiting, may
be controlled to a certain extent. I have derived considerable benefit
from the extract of Indian hemp, given in conjunction with the bromide
of potassium. The doses of Squires's extract may range from halt a
grain to two grains three times a day, with from thirty to forty grains
of the bromide, either of potassium or sodium. The pain and irrita-
bility of the nervous system are greatly lessened by these remedies, and.
thus the patient's condition rendered more tolerable.

When there is reason to suspect a syphilitic origin, mercury and.
iodide of potassium may be administered theoretically with some pros--
pect of success, but practically with very little benefit. The medioines^
should be given in frequently-repeated doses — calomel being the prefer —
able mercurial — ^so as to bring the system, as soon as possible, nnde^'
their influence.

Bloodletting, local and general, blisters, tartar-emetio, and othex*

SCPFURATITE ENCEPnALITIS OR CEREBRTTIS. 2^*3

Jculated to depress the powers of the system, are worse than

In sttppurative disease of the internal ear, probably due to caries of
tlio petrous portion of the temporal bone, preventive measures against
chronic abscess tnay do somethiog'* Leeches applied to the mastoid pro-
ud blisters behind the ear, are indicated, and mercury with iodide
Slum will afford a chance of a beneficial result, llie solution of
the bkldoride of mercury with iodide of potassium in water constitutes
^ble preparation. The flow of pxus should be facilitated, and the
ty of trephining^ the mastoid cells may be a question for consid-
timlion. The management of injuries, w ith a view to preventing abscesa^
if to be conducted upon very obvious surgical principles.

NoTR, — Under the name of Cerkbria Dn Charles Elam ' has de-
scribed an affection of the brain which he defines as "a spontaneous,
*cttt^ general inflammation of the substance of the brain uncompli-
t»iti\ with meningitis,'' Dr, Elam has;^ in my opinion, adduced very
' evidence of the existence of such u disease, but I am not quite
> that the symptoms and morbid anatomy are suflicienlly charactor-
teic to warrant at present its introduction into our nosology as a patho-
logical entity. He says ;

**It is a disease which may, perhaps, occur at any period of life,
ihliough I have never seen it before eight nor after thirty-six years of
ige. It is certainly much more frequent between ten and thirty than
it any other ages. It is uniform in its commencement as its termina-
tioa. It begins with vomiting, and it ends with death. The inter-
toftdiat* phenomena are not very striking, and the duration is from
tWiriy six hours to twelve days. It differs in the most marked manner
itnm the forms of encephalitis hitherto described, in its causation, its
HKide of invasion, its progress, and its morbid anatomy."

I cit<* the following case, which will give a good idea of the affec-
tioa in question :

"H* F., a boy, aged ten, previously in good health, vomited once
^tM morning of June IDth, In the evening I saw him, and was in-
'firmed that he was then much better. He had complained slightly of
■^^^'Wit* at the moment of vomiting, but there was little or no remains
^' *li(? pain afterward. He was not in bed, and seemed very much in his
"*^1 state, except some little languor. The pulse was about seventy,
''^'W and moderate in tone. The tongue was slightly furred, and
** bowels not quite so regular as in ordinary. Ue denied positively
J^l rpp<*at*^dly having any pain in the head, or feeling ill in any way*
^ild d#*tect no such alteration in the pupOs, nor such modification
^ *Qy ri^ble or perceptible organ or function, as to lead me to suspect

• Ob Oercbria aad othcf

of the Brmin," Loadon, ld7^ p, 82.

264 DISEASES OF THE BRAIN.

sorious disease. My prescriptions were little more than formal direc-
tions as to diet and general management. .

"For reasons unnecessary to mention, I called at the house the
next day, about 11 A. M. The mother said, in answer to my inquiries,
that her son must be better, he had slept so well, and was, in fact,
asleep still. This at once excited my suspicions, and, going up-stairs,
I found the boy pulseless, rather cold, and unable to be roused to any
degree of consciousness. From this condition he never rallied, and he
died the same afternoon, about thirty-two hours after the vomiting.

^^Post-mortem Examinatio7i^ Thirty-Jive Sours after Death, — No
trace of disease in the stomach, or any of the abdominal or thoracic
organs. Head, — The sinuses a little more full than usual, but the
membrane showing no signs whatever of disease. There was no effu-
sion, except to a very trifling amount in the lateral ventricles. The
brain-substance alone showed marks of pathological change, being very
closely dotted with red spots ; the gray matter was darker than usual,
and the white matter slightly rosy. The texture of the brain seamed
to be almost normal, neither being softer nor harder than the average.
There was no microscopical examination made of any part of the brain;
but no doubt remained on the mind that this was a case of pure, un-
complicated, idiopathic inflammation of the brain-substance."

In another case " the whole mass of the brain was so altered in
texture by inflammatory action that it could not support its own
weight, nor hold together. No sooner was it removed from the head,
and placed on a dish, than it gave way, falling prone together and
flattening like an imperfectly-made form of jelly. The commissures
were all ruptured by the weight of the hemispheres. The white mat-
ter of the brain was throughout soft, and pinkish in color. On cutting
it, it smeared the knife with a streaked stain. Microscopically ex-
amined there was no pus, but an abundance of exudation corpuscles."

My reasons for somewhat doubting that these were cases of **a
special cerebritis, uncomplicated, general, and idiopathic," are : That
the structural changes may have begun long before they were evi-
denced by any notable symptoms, and hence may have existed for
some time before coming under Dr. Elam's notice, and that the con*
dition discovered after death may have resulted from occlusion of som^
one or more of the cerebral blood-vessels. Nevertheless I am inclined,
to think that Dr. Elam has made out his case ; at any rate, he has mad^
a very interesting and important contribution to cerebral pathology.

DIFFUSED CEREBRAL SCLEROSIS.

CHAPTER Xn.

Pir FUSED CEREBRAL SCLEROSIS.

Bt tliffu&etl cerebral sclerosis is to be understood a morbid condition
of some part of the brain characterized by induration and atrophy of
ibc tissue^ and not ilistinctly circumscribed exnept by the anatomical
Umtts of the region affected.

It is not a disease w hich can be recognized with any great degree of
certainty or even of probability during life. It is^ however, a well-
tnarkcd pathological condition, giving ri:?e to very prominent symptoms.
<)( Ute years the affection has not been much noticed, except incident-
ally, by a few writers of special treatises — though, under the name of
^'induration of the brain," it received considerable attention many
v«^re agow

Th^ symptoms by which it is characterized are by no means peculiar
to it, though, when taken collectively, they give us some reason to diag-
aoiUcate sclerosis as their cause. A number of cases have come under
my observation in which the lesion was probably diffused cerebral selero-
»ii; bat I have never had the opportunity of verifying my diagnosis by
post-mortem examination. The remarks, therefore, which I shall make
•-T1 ilii* morbid anatomy will mainly be based upon the studiea and obser
^iiioiifof other writers.

SjmptoiES.^ — ^The symptoms of diffused cerebral sclerosis, like so many

titlmr brain-affections, arc comiected with the mind, with sensibility, and

^Jth tlio power of motion. It generally makes its appearance during

lafincj^ and protluces an arrest of development in the part of the brain

•ffectwi, and consequently in certain parts of the body. The initial

Pwuoiaena are those of congestion and inflammation, during the course

^' nhieh epil*^ptic convulsions frequently ensue. These may be few in

^^'^Qlber, and may cease in a few days, or they may be very frequently re-

^J^W and laat for several years, or during the whole life of the patient,

^^ mind remains undeveloped, speech, if already acquired, often becomes

^lH'rff<?f, and, if not yet present, may never be commenced. The limbs,

^***Ily only on one side of the body, become paralyzed, and do not grow

^fc the itam^} rapidity as those on the sound side. Contractions are

^•^ «pt to take place, from the fact, probably, that the normal degree

K. mntagontsni betwi^en the muscles is destroyed, and that thoso not so

■ I ^^ panUyzed as others draw the limbs in the direction of their action.

H^ ^4 quite common, therefore, in the affection under consideration, to

P^,,^^^ tl, '^ _ drawn into the palm of the hand, the WTist flexed on the

can roann on the arm, and the arm drawn backward by the

266 DISEASES OF THE BRAIN.

action mainly of the latissimus dorsi. In the lower limbs, club-feet are
produced in a similar manner.

It is not uncommon, too, to find one or more senses weak or alto-
gether lost, and the general sensibility of the body diminished on one
side.

The urine and faeces are often passed involuntarily, or else the patient,
from never having acquired a sense of propriety or cleanliness, passes
them whenever he chooses, at any time or place.

With this general idea of the symptoms, I proceed to refer some-
what at length to its history, in the course of which I shall quote several
cases in illustration of its progress.

The first to direct specific attention to the disease under consideration
was M. Pinel,* the younger, who, in a memoir read before the French
Academy of Sciences, May 27, 1822, brought forward several cases in
illustration of what he denominated " induration of the brain." I quote
the first case in full as a typical example of the affection:

Beler, agefl eighteen years, an idiot from birth, was admitted into
the Salpetri^re Hospital, June 1, 1821. The patient was paralyzed in the
left arm and leg. She could not use this arm, for the hand was strongly
flexed on the forearm, and could not be extended. She walked witii
great difficulty, dragging the left leg. Her intellectual faculties were
very much restricted ; she comprehended only the questions which were
addressed to her relative to her health, her intelligence not extending
beyond that point. She had also great difficulty in articulating the
words yes and no, which were the only words she could speak. She had
no particular habit, was always calm and tranquil, and had to be antici-
pated in all her wants. She was subject to occasional attacks of epi-
lepsy ; but, when the paroxysms came on, she had fits almost without
intermission for thirty or forty hours. They returned about every
twenty -five days. On the 4th of December, 1821, the patient was taken
with a series of epileptic fits, almost continual in character, which lasted
during four days, the paroxysms succeeding each other with inconceiv-
able rapidity. During these continuous convulsions the right limbe
were affected with violent movements. The left limbs, which had been
paralyzed for a long time, wore also strongly agitated, and the general
sensibility was abolished. The face was red, the eyes were twisted, the
dejections were passed involuntarily, the pulse was frequient and irreg-
ular, and the respiration unequal and jerking. The patient died on the
fourth day, without there having been any remission in the symptoms.
. Post-mortem Examinatio7i, — " General marasmus ; remarkable ema-
ciation of the paralyzed limbs. The cranium was thick, ebumated, and
very hard to break. The meninges were pale and healthy. The right
lobe [hemisphere] of the brain was very much smaller than the left^ it

^ ^'Rechcrchcs d^anatomie pathologique sur Feiidarcissement da syst^me nenrenx/*
Journal dr Physiologie de Magendie^ tome ii., 1822, p. 191, d teg.

DIFITSED CEREBRAL SCLEROSIS

267

ftpliied ; the convolutions were almost obliterated mid very small,
[ly in the frontal and occipitiil reg^ions. They wore large and
de<?p in the inferior part. The cortical substance was thicker than it
g«ierally is; the lateral ventricle was very small and dry. The sub*
stance of the brain, throughout the whole extent of this right lobe
pieiiii«phcre], and notably above the ventricle, was of reniarkalde hard*
nesSi aii<] it was toni with diffictdty by the fingers, the tissue separating
ia iDDgitudinal bands which converged toward the corpus striatum,

**Tlio left lobe [hemisphere] of the brain, much more developed

tttn tbc right, was of the softness and consistence of the healthy brain-

tiisQe, and this condition made the alteration in the right lobe [Kemi*

£•] more obvious."

The rest of the description refers to other organs*

In regard to this case, M. Pinel remarks that to the pathological

conditiott, the loss of the power of motion in the whole of one side^

tbdahnoat complete anniliilation of the intellectual faculties, and prob*

ibk the epileptic fits, are to be ascribed. The condition — which is fre-

ffkttki with idiots, but of which it is often difficult to estimate all the va-

tian by the distortions which it determines in the feet and the hands.

Thref other cases are adduced, in one of which the cerebellum was also

ttvpart indurated, M. Pinel, as the result of his observations of the

morbid anatomy, states that the ner\^ous tissue resembles a compact in-

Qlpiue masfl ; its consistence and density are those of hard-boiled white*

of'^gg; the cerebral substance is atrophied; it appears entirely de-

priredof blood-vessels — the eye perceiving no trace of capillaries- The

I than the gray substance; it was never observed in this last-named

Ihieiinger,* under the name of "diffused hypertrophy of the eon-
ftfctire tinene of the brain," describes the affection now under consid-
•^tioia, and refers to an interesting case reported by Isambert/ in
*'«p1i t microscopical examination of the altered tissue was made. It
^^rhsd in an idiotic child, two years of age. The ventricular walls,
^ great guiglia, the pons and peduncles, were solid and hard ; their
^^ was elastic, like caoutchouc ; the nerve-tubes in the white sub-
***co wore almost completely destroyed and an amoq>hous granular
laUtaaecB occupied their place ; there also existed newly-formed fibrous
oi^nrctive tissue. In regard to such cases, Griesinger remarks that,
*wnwe are told that a hitherto healthy and well -developed child, about
^*'« period of dentition, or during the second or third year, suddenly
"^cwne feverish, was attacked wnth convulsions and delirium, fell into

* ^*IHe Pathologic uad Tlu^raplcder pijchbcbca KninkUeiten/* Zweltc AulUge, 1861)
% iOL jUm **Kcw 8;rilc!iibam Society TraoslaUtiii,*' p. Z69.
^TimmMkmm, rvudm «t mifDolre de k Soci^t^ de Biulogie," lome U.» 1856, p, >.

DISEASES OF THE BRAIN.

a slightly soporific state, and soon afterward apparently recovered, but
with the intellectual and physical development checked, the condition
piay be due to one of two morbid processes : either there are slight con-
gestion and inflammation of the membranes, or there is encephalitis,
which, after passing out of the acute stage, suspends further develop-
ment in the affected parts. The mind, therefore, ceases to expand ;
walking, if begun, is arrested ; speech remains as it is, or is altogether
lost ; one side of the body does not grow so fast as the other ; and con-
vulsions, paralysis, and contractions, are present.

A case in point, referred to by Griesinger, I quote from Calmeil : '

" M. Alfred, bom at Havre, single, aged twenty -two years, came to
the Bicetre, where he resided twenty-two months : he had been an in-
valid since infancy.

" Until about three years of age, he had exhibited no peculiarity as
regarded intelligence—resembling other children of his years.

** At this period, however, he was attacked with measles, which was
considered mild in form, and from w^hich he had nearly recovered, when
he was seized with a succession of severe eclamptic paroxysms. During
twelve hours, it was impossible to rouse him from the coma, and gen-
eral convulsions were present almost without interruption.

"The day after, it was perceived that he .was deaf, blind, and in-
capable of articulating the least sound ; the convulsions had ceased.

" At the end of fifteen days he recovered his hearing ; after a year
he could say a few words ; but the retinae continued insensible to im-
pressions of light.

" It was now perceived that he walked with a certain degree of diflS-
culty, and that he could hardly use the right hand. At times, also, he
lost consciousness, but without falling, and it was subsequently recog-
nized that these attacks were epileptic.

" Until the age of thirteen, the intelligence of M. Alfred underwent
scarcely any development, and he remained imbecile notwithstanding all
the efforts made for his improvement. He nevertheless acquired a knowl-
edge of a certain number of words, and he could make himself under-
stood whenever he had a want to gratify.

" At the age of nineteen he presented the symptoms of an almost
complete state of idiocy. He comprehended some things, and covHd
imperfectly articulate a few words. He was not evilly disposed, but he
was incapable of attending to his person, and even of eating without
assistance.

" He could take a few steps by supporting himself against the wall,
on articles of furniture, or a cane, but he dragged his feet on the ground,
and his right leg appeared to be weaker than the 1^. The right arm
was contracted and almost immovable. Tactile sensibility was not ef-
fected, anywhere. He did not appear to perceive objects placed imme-

* "Trait6 des maladies inflammatoires du cenreau," Paria, 1869, tome ii., p. 411.

DIFFUSED CEREBRAL SCLEROSIS.

dSftt4^Ijr before his ey/'s, and the pupils wore dilated and insensible to the
foddea nccession of light. As regarded the bladder and rectum, ho
rrftcttmti*il thein without seerning to exercise the least restraint of clean-
Kmeas or propriety.

**Tbe epileptic paroxysms occturred with long iiiter\'al8 between
tbcnif and presented no characteristics worthy of special mention. The
ion was pale, and the body emaciated and notably woak,
ng the month of January, 182T, there was frequent cough,
eciBbiQed with abundant expectoration, diurrhcea, and other symptoms
c»f phthisis.^' He died in February of the same year^

Auiojfsi/, — The whole of the right side of the body was much less

than the left side. Tlie rij^ht arm and leg were especially

and thin, *' The face was free from distortion, and the era-

nhtm^ without being deformed, was small and very narrow. The greater

the cranium was abnormally thick, and contained an excessive

of calcareous matter.

QMeotia surfaces^

**A very considerable quantity of serum was infiltrated into the
lo^es of the pia niatr-r — principally toward the middle and convex
wrfirc of the two cerebral hemispheres. The pia mater was thickened,
l»ut was not adherent to the convolutions,

** The left cerebral hemisphere was notably smaller than the right ;
4e posterior lobe being particularly remarkable for its diminution.
IV convolutions were flattened, and w^ere as thin as the blade of a
bife, were resistant to the totich, and were of a clear yellow color,
TV middle and anterior lobes w^ere neither of them of ordinary size,

**The posterior lobe of the right hemisphere was less develoj>ed than

lUi Wealthy brain, but the number of atrophied convolutions w^as small.

^Oq cutting into the left posterior lobe with a bistoury, its tissue

to be white, compact, homogeneous, and very resistant. It

tjd that the cerebral substance had become doughy, and that

*« '^lejiient, foreign to its nature, gave it an excessive degree of hardness,

**0n the right, the atrophied convolutions of the posterior lobes

^ftj difficult to cut ; their structure was compact, but the induration of

^nervous tinsue did not extend deeply into the thickness of the lobe.

^ fo all other parts of the brain the white and the gray substance, as

^U on the left as on the right side, were apparently, in all respects, in a

i^lltl.v ^' I.^n,

**T ra striata and the optic thalami were free from change,

•'itheT iM r<*giird<?d th«nr volume or their structure.

•*The pons Varolii, the tubercula quadrigemina, and the pedundoa
0/ the cerebrum, and cerebellum, were in a normal state.

270 DISEASES OF THE BRAIK.

" The optic nerves were atrophied, of a glossy white color, and very
hard."

Other cases, similar in general featiires, are adduced by Calmeil.

In the very interesting monograph of Cotard,* to which reference
has already been made, the relation of sclerosis to atrophy of the brain
is clearly pointed out. As indicating a certain set of symptoms, in
existence with a definite pathological state, I quote the following case,
No. XXIX. of his series.

" C, aged fifty-eight years, an inmate of the Salp^tri^re since 1828,
entered the infirmary on the 25th of April, 1865, under the charge of
M. Charcot.

" She gave the following information, which she said she had from
her mother, and from other persons who had brought her up : At the
age of eighteen months she had three attacks of convulsions, which left
her paralyzed on her right side. She had never had convulsions since.
She had already begun to walk when the seizures took place, but she
did not walk again till she was three years old.

" According to the information given by the superintendent of her
ward, who had known her since her entrance into the hospital, her intelli-
gence had always been weak; she was incapable of attending to herself;
she could read tolerably well, and could sign her name ; she had always
spoken without difficulty.

" She had been employed with coarse sewing, and had invariably
been docile and attached to those who took care of her.

" Her health had always been good, though she had, when about the
age of twenty-five or thirty, several attacks of hysteria. Menstruation
had been regular, and had ceased when she was forty-five.

" For about a year the patient had been the subject of frequent at-
tacks of vomiting, or of epigastric pain. At the time of her admission
to the infirmary, she was very much emaciated and very cachectic.

" Her intelligence did not appear to have been recently enfeebled ;
she could read, sign her name, and speak without difficulty.

" Her senses seemed to be intact ; sight was good in both eyes, and
the pupils were equal. There was no facial paralysis, and the tongue
• was protruded straight.

" The right arm was emaciated, atrophied, and contracted ; the fore-
arm was pronated and semi-flexed on the arm ; the hand was flexed on
the forearm, and inclined toward the ulnar side ; the fingers were flexed
in the palm of the hand, particularly the ring and little fingers ; the
index-finger was semi-flexed, and the thumb was extended.

" It was possible, without very great force, to bring the several parts

of the limb almost into a state of extension, but, as soon as it was left

to itself, it resumed its habitual position. The patient could execute a

few movements with the shoulder and the elbow, but the wrist was ab-

* " ttude 8ur Patrophie partielle du cerveau," Paris, 1868, p. 49.

DIFFUSED CEREBRAL SCLEROSIS.

271

•* The right leg was less atrophied, and there was no other defonnity
tban a ' quinus. The patient walked with a cane.

**1 'ility of the right side was intact, and no very notable

differestce of temperatiire waa obsenred between the healthy and the
ilyzed sides.

^Th4* patient died May ITth, after symptoms of acute peritonitis.
*^ Auiopmf^ — Cancer of the stomach, circumjacent abscess, purulent
peftlomtia,

"No exterior deformation of the cranium; on the left side its walk
were thick, doubly and triply so at some points ; the frontal sinus ex-
tended to the left of the mesial line, and commuuR'ated with a large
cavity aituated in the orbital arch, which was composed of two thin
oMcoua Iam€»Ua?«

"The left middle fossa was smaller than the right, and the right
oeftbf»Uar fossa was smaller than the left,

** The dura mater being incised, a largo quantity of serum escaped
trom the left side. The left hemisphere was very small, shriveled^ and
ift Imgtb and breadth scarcely two-thirds the corresponding dimensions
^f ibe right hemisphere. The convolutions were pressed together, were
ijwd, atii] of a whitish color.

**0n the external face of the middle lobe, behind the posterior mar-
pJtl eonvolutionf and on the prolongation of the fissure of Sylvius,
tlM'f^ WM a deep depression running upward and backward, and three
"^r f'jur centimetres in length. At the bottom of this depression the
fiooToJutiona wei;© reduced to little ridges, which were hard, and of a
jrtllow color.

**Tlie ventricle was conaiderably dilated ; the corpus striatum did
nol appear to be perceptibly diminished in volume, but tlie optic thala-
'^ii« irii hardly one-fourth as large as that of the opposite side.
^t'fip Has cousiderable atrophy of the left crura of the fornix, and of
^^^ mammary t uWrcle.

**The olfactory and optic nerves of the left side were apparently
^tiiy ; the tubercular quadrigemina were not atrophied*
^*Tbe right h'^mijsphere was healthy.

**llie rigfit hrtutsphere of the cerebellum and th<? middle cerebellar
M'lnde of the same side were atrophied,"

EiEamined with the microscope, the indurated convolutions of the
Wl Iwjmujphere presented an enormous quantity of amyloid corpuscles
tail of nuclei of connective tissue :

CAam L — J* S,, a boy, aged five years, was brought to me in the
auiumii ol 1869| to be treated for epilepsy. The paroxysms occurred

272 DISEASES OF THE BRAIN.

several times a day, and had originated when the child was two years of
age, in consequence, as the mother thought, of a fall.

At that time he could say a number of words, and was rapidly learn-
ing to talk ; his intelligence was good, and he had been walking for
several months.

But after the first convulsion he ceased to speak and to walk, though
he continued up to the time I first saw him to give his attention to very
striking objects, such as noisy tops, bright-colored articles, and, above
all, music and soldiers. During this period he had at least six exacer-
bations, characterized by pain in the head, repeated convulsions, and
coma.

When he was about two years and a half old it was observed that
he did not move the left arm and leg so freely as the right, and soon
afterward he ceased to move them at all. The toes then began to be
drawn under the sole of the foot, and the heel was raised. Then the
leg became flexed on the thigh, and soon afterward the fingers of the
left hand and thumb were gradually bent so as to prees strongly against
the palm. The wrist followed, and then the forearm. Both limbs were
greatly atrophied.

When he came under my examination he was having epileptic con-
vulsions, both of the grand and petit maly every day. There was no
deformity of the skull, though it was certainly small for his age. His
mind was feeble, and he did not give attention to any remarks made to
him, but bright objects at once attracted his gaze, and he made efforts
to get hold of them.

I examined the fundus of the eyes with the ophthalmoscope, and
discovered an aniemic condition of the retime and atrophy of both
optic disks.

I gave it as my opinion that the child was suffering from diffused
cerebral sclerosis, involving the left hemisphere ; and that there was
scarcely any prospect of material amelioration in his mental or physical
condition.

Case II. — A female, aged eight years, entered the New York State
Hospital for Diseases of the Nervous System, June, 1870, having pre-
viously been a patient at my clinic at the Bellevue Hospital Medical
College.. When quite an infant she had suffered from epileptiform con-
vulsions, which had been almost immediately followed by paralysis of
the right upper and lower extremities. The convulsions recurred at
short intervals, and atrophy of the paralyzed limbs, with contractions
of the fingers, hand, and forearm, supervened. She learned to walk,
however, quite well, and also to talk without any very notable defects.

Her mind was weak, and she was extremely silly in her behavior; she
had never learned to read.

Under the use of the bromide of potassium her epileptic paroxysms
ceased, ))ut the contractions and atrophy of the right arm resisted

DIFFUSED CEREBRAL SCLEROSIS,

llvAtixienI by galvanism and mechanical appliances. The leg acquired

Biscli txH>re power under the treatment than it had previously possessed.

CiSE IIL — W. W., a gentleman, aged forty-three, came to me, De-

t*tl>rr 11^ 1869, to be treated for what his physician and friends regarded

- fcening of the brain.

Ahaut six months previously he had experienced, on awaking in the
^iniin^, great dilficulty in extending the left hand and fingers, and
tfinmgh the whole day there was a decided tendency manifested for the
\xtter to close, and the band to be flexed upon the forearm; and this
grftdtuinT, day after day, became stronger, till at last neither the hand
■or fingers could be extended.

Then the corresponding lower extremity bc'came involved in a similar
mmui/tr^ and, about a month after noticing the first symptom, ho had
aa epileptiform convulsion, and this was repeated twice the following
day* Since then the fits have occuiTed at intervals of four or five days,
Wttb thc! contractions in the limbs of the left side, there was gradually -
d»g paresis until, when he came under my observation, both ann
l^g wer© almost completely paralyzed* Atrophy of both extremi-
tiea woji present to an extreme degree, and sensibility and electro-mua-
cuUf coutractibility wore almost entirely abolished.

His mind was also notably impaired. He laughed immoderately at
•fcrjr qttaatioD I put to bim, and bad a decided expression of imbecility.
Bh^kaoch waa not affected to any remarkable degree, except as regarded
tilienia ilowsaia of utterance. He had, previously to his illnesa, been
a imly and quick speaker My diagnosis was diffused cerebral sclero-
iii, lad I gav« an unfavorable prognosis. The treatment, which will be
«>o«dcred under its proper head, was, however, succesaful to a very con-
*i<l«tble extent.

It will be seen, from the foregoing account of the symptoms, that
diiuBeil cerebral sclerosis is characterized mainly by weakness of intel-
•w*, pacalyaia, and muscular contractions.

Oilim. — The predisposing causes of the affection under considera*
tioQaranot thoroughly undecstood. The disease appears to be much
•m^ frequent in infancy, although it lasts to the period of old age, and
ttMimea originates at an advanced time of life.

TW exciting causes are likewise imperfectly known. Injuries of the
llroll from falls or blows, and ha^morrhagic cysta, appear to have some
uiflaeisoa in originating the disease, but more generally it is developed,
mfkr aa we can perceive, spontaneously,

DtignOBtS* — The lUagnosis of diffused cerebral sclerosis must always
be sioro or leas uncertain, for the rt*ason that the symptoms are met with
IQ oilMsr very differaut affect lons^ In children a similar set of phenom*
•oa nay bo the conaequenee of arrest of development in the brain with*
out any alteration of its structure recognizable by our means of obser-
lofi. In the case of an idiotic child affected with convulsions, hemi*

274

DISEASES OF TUB BRAIK.

plegia, and muscular contractions, I found, on post-mortem ex&uuo&Uon,
the left hemisphere markedly smaller than the right, but I could detect
no change of any part of its structure.

Symptoms like those met with in diffused cerebral sclerosia may re-
sult from brain-tumors of various kinds.

In adults the disease is readily discriminated from cerebral hasmor-
rhage and embolism by the gradual character of its advance^ and by the
mental symptoms being more strongly pronounced. But from aoftfiti''
ing the diap^nosis cannot always be made out, and an opinion must be
formed from the history and phenomena in each individual case*

From thrombosis the diagnosis is equally dilHcult, Perhaps tho di^
tinction may be made both as regards softening and thrombosis by the
facts that, though contractions are met with in both these diseases, they
are not such invariable accompaniments as they are in diffused cerebal
sclerosis, and that they are never, as occasionally in the latter affection,
a priinar}' symptom.

Prognosis. — ^The prospect of complete recovery is very gloomy^ a^d
even amelioration has hitherto been regarded as out of the question. I
am inclined, however, to think, as the result of my own experience, that
the condition of patients, apparently suffering from the afTection iw
question, may be decidedly improved by suitable medical treatmeiiL
I have several times succeeded in arresting tho convulsions, stieogth-
ening the mind, increasing the strength and sensibility of the paralysed
mem hers, and relaxing the contractions. My success baa beea mucb
more decided in cases which had originated late in life — probably, for
the reason mainly that the ilisease was seen earlier in its course.

Morbid Anatomy, ^ — This division of the subject has already been cott-
sidored iiroidentally, to some extent, in the remarks made under the
head of s\inptoms, and in the detail of cases quoted.

The most obvious feature detected by ordinary observation is the
increased hardness and density which the cerebral tissue has acquired.
This generally occupies a considerable portion of one lobe, or may ei-
tend through the whole of it, or may even affect a whole bemisphoTe,
It is not distinctly circumscribed, but diminishes in intensity from the
centre to the periphery, and, according to Pinel, never invadcia the gray
substance.

Tlie increased density is attended with atrophy when the diseaie
affects the adult, and with atrophy and arrest of devalopmenl wheo
children are its subjects.

In order to understand the essential nature of the morbid process
which causes the brain to become indurated, a few words in regard to
cerebri^l histology are necessary.

Besides the nervous tissue of the brain, there is another anatomical
element present wfvich fulfills the function of binding the cells and fibres
together, and giving the whole substance its normal degree of ootisist-

DIFFUSE CEREBRAL SCLEROSia

275

mee. According to Virchow/ this, althouo^h analogous to, is different
is aottio respects from ordinary connective tissue. He gave to it t!»e
■ftme af neuroglia or nerve-cement.

I>iffllBed cerebral sclerosis consists tu the hypertrophy or lucrcas^d
forfnation of this tissue, and the atrophy or disappearance of the proper
werroaa substance* Atrophy of the brain may, however, be due to
cellar causes than sclerosis, aa in the ca^e reported with great minute*
oesi by Schroeder van dcr Kolk,* and several of those cited by I>alle-
flonodf* Turnerj* and other writers,

PftlAoIogy. — ^The symptoms wliich result from diifused cerebral scle-
nms are those which we might expect to be the consequence of & con-
dilloci which essentially consists of a dtBappearance of that part of the
himni-tSBStte ^capable of producing- or transmitting nervous force, and the
Adistiiution of another histological clement which is of secondary im-
pontaiice, They all indicate deficient cerebral power. It is with the
twmia ad with a muscle undergoing atrophy; less force results from its
acibo in correspondence with the advance of the process by which the
cbavactcnstic anatomical elements disappear.

Doobtle^s, if we had the opportiinity of more thorough study of

tbe symptoms of diffused ccrobral sclerosis, and comparing them witll

line cotidition of the brain as found by post-mortem examination, we

•iwakl find that they varied considerably in character, according to the

part tffecte»:l, and wo shoutd probably have reason to believe that the

acrvp-cclls which had disappeared — motor, sensitive, or trophic — were

ta ejuict pathological relation with tlie symptoms observed. Thb spe-

'-iil Hr.iiit has been well studied by JLM. Duchenne de Boulogne and

Y* m a recent paper, devoted to a somewhat different diaeaae,

uui tQ which I have recently been enabled to add a few important

data.

Tnatment. — TJus tli vision of the subject has scarcely receiveil any

•*1*»tJon from authors. My experience, however, has sufficed to con-

•^KKfr we that wo can occasionally improve the condition of tlie patient.

If there are epileptio convulsions, they may be prevented by the ad-

ffiiniitnition of the bromide of potassium, in doses of at least twenty

ICiiji*, three limes a day, to an adult. larger doses may be necessary.

' ' ' cessation of the convulsions, it will aometimes be found that the

' ■A^non at once begins to be developed.

The paralysis and contractions may sometimes b<^ lessened by the

' "^Cclkilar P«tho»oKr/* Chance's tmnsUlion, London, 1960, p, 277.

• *' 1 C»m of Atroithj- of the Lofl Hi'mbphcrt* of the Bratn/* etc. New SjdenU<n» So-
«^T TnaflUtiati, L<m *un, \f<i^\>

• r>. tit

• •• IV r*tTnpMr pnrtTHlf on Ufinnt6f»1c ^u cerrtfUi^** etc», PaH», lfi5fi.

' ***t' ii« **t rhnmiqiift do« cellules aerveusea dc la tno«1lc et da bolbe

iiiiiiir -« 1^ Ph^fHohsfu, Ko. 4, JuilUl ci Ao6t, 1870, p. in.

276 DISEASES OF THE BRAIN. •

persistent use of both the induced and primary galvanio currents. The
first named will often in the beginning fail to act upon the muscles, in
which case the latter should be employed. This is always better for the
contracted muscles than the induced current. For the relief of the pa-
ralysis it should be interrupted, for the relaxation of contractions it
should be constant.

As regards the central lesion, I think it may occasionally be reached,
when it has not had time to become very extensive or profound. And
the best and really only means I know of are, the primary galvanic cui^
rent passed through the brain, and the administration of the chloride of
barium.

In using the galvanic current, the electrodes — ^wet sponges — should
be applied over the mastoid processes, and kept there for a period not
exceeding three minutes. Fifteen of Smee's cells will afford a current
of sufficient intensity. The application should be made about every
alternate day.

The chloride of barium may be given in doses of about a grain thieo
times a day. I usually administer it in solution, according to the follow-
ing formida: $. Barii chloridi 3 j? aqusB dest. § j, M. ft. soL; dose, gtt.
xij three times a day.

I am unable to say that these measures have actually removed the
supposed sclerosis of the brain, and caused the reformation of the atro-
phied cells, but I am very sure that symptoms such as are attendant
upon diffused cerebral sclerosis have several times been measurably dis-
sipated by its influence. Thus, in the third case mentioned as occurring
in my practice, the mind improved, the epileptic paroxysms ceased, the
contractions were relaxed, the paralysis lessened, the affected limbs in-
creased in size, and the further progress of the disease was arrested.
At the present date (December 30, 1870) the gentleman is able to take
care of himself, to walk tolerably well, and to use the formerly-para-
lyzed arm for many purposes. In three other cases a like treatment has
been productive of almost as marked a degree of benefit.

CHAPTER Xm.

MULTIPLE CEREBRAL SCLEROSIS,

In multiple cerebral sclerosis the lesion involves several parts of the
same ganglion, and consists of plates or nodules of sclerosed tissue
scattered throughout its substance.

It is only of late years that the affection in question has been par-
tially recognized as a distinct pathological condition, associated with
certain symptoms. These symptoms were formerly, and still are to a

MCLTIPLE CEREBRAL SCLEROSIS.

277

(tcnt^ confounded wit li other groups similar in several prominent
, but different altogether in anatomical relationSj normal and ab-
aofinsl.

Tbtts, under the designation of paralysis ag-itatis, were comprehended
Uw phenomena due to multiple cerebral sclerosis, multiple cerebro-
I ipiti&l selerosis, and muscular agitation, general or local — the result of
my dwginiitar lesions, or without discoverable morbid changes of
WDJ tdful — ^the one symptom of tremor sufficing to bind them together,
Evieii by late writers the distinction is not clearly made out.

It ifi^ in the present state of our knowledge impossible to say in all
CBftCB irhal part of the intru-cranial mass is affected. Still, we are not
Imkogether without data on this point, and an attentive consideration of
I Ike tjmptonis will often, at least, enable us to say what ganglion of the
tBMplialon is the main seat of the lesion. But, mindful of the fact
dni this work is intended to be practical, I shall not venture to deal
with palhological refinements, but will point out, with as much succinct-
Hen ttS possible, one form of the morbid process tinder notice — a form
vlaA 1 think I am enabled to describe, from my own observations, with
ooQiid^nble accuracy. That fonn I shall designate —

MLl-TirLK }>CLEROSLS MAINLY AFFECTTIKG THE IIEMISPBERBS.

Symptoilis* — ^ Among the first symptoms noticed in this affection is
fdni, which occurs in sharp paroxysms of short dnration. Sometimes
lit 9&iUHition is as instantaneous as an electric shock. It is rarely the
«it that there is any extreme constant pain experienced, though a
Ming of fullness or constriction is occasionally more or less perma-

In a few cases the first observed symptom has been an epileptic

ll is not uncommon to meet with disorders of sensihihty in other
f^tUol the body; and these may either be anaesthetic or hypenvsthotic
o» chiractrr. Probably the most common is a numbness of the ends
^ tie fingers or toes, which gives the sensation of cushions when ob»
i'^awf touched, and which is generally confined at first to a single
•PP«f or lower extremity* Shooting pains, something like electric
■Wb^ arc also sometimes experienced. The progress of the disease is
••>Oft invariably slow, and hence several months may elapse before any
•■•Jiini of motility are experienced. These, however^ are the next
^f^t|i(DQM to make their appearance, and are generally first manifest-ed
•ytke oceorrence of tremor or trembling.

Trrmor usually, but not always, is gradual in its development, and
''^^tbe rt-ntrioted to narrow limits. It may lit first only be felt when
** patient is unusually quiet, and has not his attention engaged. Thus
* gfefillenMm told me he had, for several months, only been sensible of

278 . DISEASES OF THE BRAIN.

a vibration in his arm when he lay down at night. It was then — from
the description he gave me — limited entirely to the extensor indicis of
the left hand, and was, in the beginning, not strong enough to move
the finger. When I first saw him, several years afterward, both arms
and one leg were strongly agitated.

In another case, whidi I saw almost from the very beginning, the
tremor was restricted to the same muscle for several months, and then
gradually involved the extensors and flexors of the hand. And, in sev-
eral other instances which have come under my notice, the onset was
equally gentle. But, as I have said, this is not always the case. A gen-
tleman consulted me in the summer of 1870, who, after having ex-*
perienccd severe darting pains in the head and through the limbs on the
right side, was suddenly, while in his field overlooking some work, seized
with a violent trembling of the right hand, which continued for several
minutes, notwithstanding his efforts to prevent it. A few days subse-
quently, he had another accession of a similar kind in the same limb,
and by degrees the intervals became shorter, until, in the space of a
month, the tremor was constantly present except when he slept, and,
when I saw him,' had extended to the whole arm, and to the lower ex-
tremity of the same side.

In another case, a gentleman, much addicted to excessive mental
exertion, was awakened one morning by a violent agitation in his right
foot. He had been under my care several months previously for severe
headache and inability to sleep, for which, believing them to result from
ihordinate intellectual labor, I had recommended mental rest and horse-
back exercise. Under the use of these measures he had apparently quite
recovered, but against my advice had resumed his literary labors.

He was not very confident how long the shaking of the foot had
lasted, but thought it was not more than a few seconds.

Several days afterward, while writing, his right hand began to trem-
ble slightly. He ceased his occupation, and rubbed his hand with the
other. The tremor stopped for a moment only, again began, and has
scarcely ever since been absent. The whole side eventually became
involved.

The tendency of the tremor is always to extend. Beginning in an
extremity or a group of muscles, or only in a single muscle, it goes on
attacking others, until at last all the limbs and even the head may be-
come affected. By preference, the advance of the tremor is lateral,
that is, if an arm be first invaded, the leg of the same side next suffers,
then the other arm, and then the corresponding leg. Usually the head
is the last part attacked; but this is not always so, as I have seen sev-
eral cases in which the trembling began in it.

For a long time the tremor is to some extent imder volitional con-
trol. A patient, for instance, will slap his tremulous hand on his knee
and for a few seconds can manage to keep it quiet, but it soon begins -

MtTLTIPLE CEREBRAL SCLEROSIS.

to sliake ag-mn, uuJ, thoun'h perhaps a so^cond time he niny arrest its
nameinesits by a like process, the period of rest is shorter. Any change
«( |»osition is calculated to quiet the tremor for a time, and thus the
|Mtient is every few minutes moving his arms or legs in the attempt to
g«!l a little respite.

It Li always increased by emotional disturbance of any kind. A
Jamb which may ordinarily be but slightly tremulous, will shake vio-
liotlir from the excitement or anxiety produced by making a visit to a
pli^ciaiu The effort to keep it quiet will also often increase the tremor.
For a very considerable period after the beginning of the tUseaso, the
tbftklDg ceases during sleep, but eventually this state affords no respite,
Sttd tKe patient is thus deprived still further of his physical strength.

It is not often the case that the muscles of the face are affected very
«ti{y ill the disease, but they frequently become involved at a later
fmocL In several cases 1 have seen a constant tremor in the upper
ej«Uii o£ one or both sides, and in one instance this was the first mani-
fettmtiou of the disease.

In another very remarkable case the first indication of tremor was
pwetived in the left eyeball, which wa.s, by clonic spasms of the inter-
nal rectus muscle, kept in a state of motion producing a kind of nys-
Ugmti&. The upper lid of the same eye next became affected, and then
Iht tremor appeared in the corresponding arm* The upper lip I have
itfeml times sc« n trnnulous, causing thereby an indistint^tness in the
fttlieulation.

I have never observed other muscles supplied by the facial, or third
o«rv<?, to be involvetl in the tremor.

Occasionally the lower jaw is rendered tremulous from the seat of
tlifldticase being at the origin or in tlie course of the fifth ner^'e.

Hic tongue is sometimes affected with tremor, generally at first on
<id|<)nc side, and I am inclined to think that the muscles of tb© phar-
JttKind larynx do not invariably escape.

The tremor is not, as some authors have asserted, only manifested
^fcwi voluntary movements are performed. Tliis is probably the easi^
ttleist in the first instance with multiple cerebro-spinal sclerosis, but it
«»Tlwftly ts not in the purely cerebral form now under consideration,
*icooud ' calls attention to the error which has been committed relative
^ thi« point, and my own experience is uniformly in support of the
TWiioii he expresses.

The next symptom of importance to make its appearance is paraly-
*•; and, when the sclerosis is limited to the hemispheres or begins in
ttoiB, it always follows the tremor. On this point I have insisted in my
iBCfiiies to the cUss of the Belle vue Hospital Medical College, as an
laiportaot indication of the fact that paralysis agitans is often a cere-
knl^Gsoise, and I am glad to find so exact an observer as Jaccoud* as*
* •*fV«ia dc po-iholofi^e interne," p. lU, Cp, 0iloe, cU,

280 DISEASES OF THE BRAIN.

serting that the paralysis is often preceded by muscular agitation or
trembling.

At first the loss of power is slight, and, like the trembling, is limited
to a single muscle or group of muscles, but it gradually extends until
it involves the limbs of one side, or even of both sides. According to
my observations, it follows the course of the trembling, no limb being
ever paralyzed till it has for some time been affected with tremor.
In the face, however, the paralysis appears to be independent of the
tremor.

The period which elapses between the appearance of the tremor and
the accession of the paralysis varies in different patients, and even
greatly in the same patient. Thus some muscles may exhibit notable
loss of power in a few weeks after they have begun to be agitated, while
others remain free from paresis for many months.

When the loss of power affects the extensors or flexors — especiallj
in the former event — contractions may take place, as in diffused cere-
bral sclerosis, and the limbs are thus more or less distorted. The most
common seat of this phenomenon is in the upper extremity, and it gen-
erally begins in the fingers, extending gradually to the wrist and elbow.
But in some cases, even though the antagonism between certain groups
of muscles be destroyed, there are no contractions. The muscles of the
head, face, and trunk, do not escape. Strabismus, ptosis, and facial
paralysis, are thus produced, and the muscles concerned in speech, in
deglutition, and in respiration, likewise become involved. The sphinc-
ters, according to my experience, are rarely paralyzed in the early stages
of the disease, but I have several times witnessed paresis of the bladder
among the primary symptoms.

A marked symptom which I have observed, and which can only be
distinctly shown by means of the dynamograph, is the inability of the
patient to maintain a continuous muscular contraction, for even a short
period. I have noticed this as among the very first indications of pa-
resis, and I am disposed to think it exists even before the tremor is no-
ticed. Thus, a gentleman occupying a prominent public position, and
in whom I had diagnosticated multiple cerebral sclerosis mainly affect-
ing the hemispheres, instead of making a straight line with the pencil
of the instrument, traced one of which the following cut is a facsimik:

Fra. 20.

Repeated efforts only gave worse results.

MULTIPLE CEREBRAL SCLEROSIS.

S81

In anotber case, that of a gentleman referred to rae bj my friend
Dr. Van Buren, the line made was as follows:

Fio. SI.

Here the patient was able to maintain the contraction at its original
force lor only about tbe sixth of a minute — the time required for tbe
paper to traverse the pencil being exactly half a minute, and a third
part of the line being horizontal.

Tbe ability to courdinato tlie affected muscles is always impaired,

and thus in voluntary movements there is agitation independently of

IIm c«ot<?ric tremor. This is seen not only in active movements, but in

pMsiTc muscular contractions, such as those by which an article i3 held

with the object, but are nioved about in a disorderly manner. The

tneoOrdination is manifestly connected with the inability to maintain a

Wagtbened muscular contraction to which reference has just been made.

Sometimes, by tlie strong effort of tho will, assisted by the sense of

*ight, these last two difficulties may for a little while be overeome. A

pntlfman now under my charge, suffering from the affection in ques-

tioii, oinnot, for instance, carry a glass of water to his lips except by

loeidiig at it Bxedly, and concentrating all his volitional power upon

ihe ict His lower limbs are not yet affected, and he consequently

cm cotJrdinato them, in walking and other movements, perfectly well.

In another case, a lady, affected with multiple cerebral sclerosis, un-
*l<irlook to help hor invalid husband to rise from his chair; a band of
^fiuiic happening to pass the window, she turned to look at it, and, at
^^tt* relaxing her hold, let him fall to the floor and injured him severely,
Zenker* reports a case in which there was a similar loss of the ap*
ppftdttion of the state of the inuscle; and another is mentioned by
»*ynolds,' under the head of ** muscular anaesthesia.'' I am very sure
tnit many cases of this !ast-name<l affection are instances of multiple
***bral selerosls of other ganglia, and I shall presently more specific
^y refer, under a tUfferent head, to two remarkable cases which have
^°*^«ntHi in my own experience.

Another phenomenon closely rcdatod with this incoordination is gen-
*'^% prcsf^nt in multiple cerebral sclerosis, and that is, that the patient
"^••^ftthat innate or early-acquired knowledge of the exact situatinn of the
^^nl parts of his body. We can all of us, not thus affected, close our

* **WttL Bdtntg zar Sklcru6c d«s Hiras tmd Riickcnmarks," MenU %nd P/tu/ir*§
^'i^Ar^f^r raUitn^^ .\fr.{isin, Bd. xxir,^ 1865.
' "^KiftU^ of Iftfdic'mi*/' vol li., p. S30.

i*'

Itb a^^ ^'* \ Into \vis ^^'' aenO' ^° J ^^^tce^t bJ groad^"''^', „d
*^^ "? i vs ottett » * ,,i con" vv''^''"^^ vvodev wj »,u\^<'«?.

cow\d vf^ m

MCXTrPLE f EREBILVL SCLEBOSIS.

Sametiitic% however, the tendency is to go backward. Tliis was the
es0e, to a remarkable extent, in a gentleman, a resident of this city,
who was sent to me by Prof. Van Buren. Every time he rose from his
choir he was forced to take several steps backward, and it was only by
coiitftant mental efTort that he was able to go forward at all.

*nitJ tactile sensibility is generally impaired from a very early period
III the course of the affection, and thii.s, the two points of the aisthesiom-
■trr must be more widely separated than in the normal condition of
fn»' system, in order to get two sepanitc impressions. This atiicsthi'sia
r« ars no necessary relation to the region of skin covering the affected
ntusctcft. According to my experience, it is most marked at the termi-
umI extremities of nerves.

Numbness of different degrees, pains of various kinds, increa&ed or
diminished temperaturOj and excessive hypersesthesia of the skin, may
sbo exiht.

The Bpecial senses may be affected to a variable extent. Thus there
Hiaj be amblyopia^ or even complete blindness; the taste is very often
lo^ireMi or abolished, and the hearing rendered less acute.

Tlie opiithalmoscope should always be employed to examine tim
fmidua of the ej^e. The condition generally found to exist is white
atrophy of the optic disk, which is identical in general features with
ieletoiiiJt. Tlie vessels of the retina will usually be found small, the
bruushes of the veu»s few in number, and the choroid of a paler hue
lUn is natural.

The course of multiple cerebral sclerosis is progressive.
The patient is finally unable to walk, the friction of his shaking body
tfuiuit the bed abrades the skin, the dejections are passed involuntarily,
*nd ho dies either in coma, in convulsions, or by a gradual process of
MlEoniji^ his mind participating in the general decay. The duration of
^ disease varies from a few months to eight or ten years. Generally
it niiiir its course in about live years.

Ollliaa* — Age is certainly one of the most powerfid predisposing

**U)»es of multiple cerebral sclerosis mainly affecting the hemispheres,

^c&using the symptoms heretofore classed as paralysis agitaus. Tlius,

^ Utirteeti oases ui which 1 diagnosticated the disease in question, all

*we over fifty years of age, and six were over sixty. I have seen nu-

"•Wtww cases of paralytic tremor in younger persons, but the morbid

cooditioQ bad scarcely any points in common with that now under notice*

f^MSi however, are on record in which young persons were the subjects.

TWs ia aomo evidence to supi>ort the theory that it is sometimes herodi-

tAT\\ but xlw whole subject is so confused in the minds of most authors,

llmt it in difficult to make out clearly what they refer to under the des-

i^ditioti of paralysis agitatis. Of the thirteen caaea occurring in my

ite and hospital, five had immediate ancestors who
I some form of tremor and paralysis. Whether the

284

DISEASES OF THE BRAIN.

lesion was purely cerebral, cerebro -spinal, or whether the disease was en*
tirely functional, I was not able to decide irora the information given.

The influence of sex is more readily ascertained and is very evident.
Eleven of my cases were mules and only two females.

Of exciting causes there are many. In two of my cases it followed
immetliately on attacks of scarlet fever, in two it was a sequence of
typhoid fever, in two it ensued after rheumatismj in two it was probably
svphilitic, in two it was apparently excited by great emotional disturb-
ance, in one by inordinate muscular exertion, and in three no cause could
be assigned, or at least there was not, in my opinion, any sufBcient ex-
citing cause to be discovered.

Diagnosis, — Multiple cerebral sclerosis has heretofore been con-
founded with other diseases, and its very existence as an independent
afftwtion is very illogically questioned by some writers. There is, of
course, no anatomical reason why the afiFectiou should not be confined to
the brain as well, as it certainly is in some cases, as to the spinal cord.
To this point 1 will return when the morbid anatomy and pathology are
discussed, and, as in the foregoing account of the symptoms and causes,
will base my remarks under the present head mainly on the results of
my own experience.

The occurrence of '* head-symptoms" is sufficient to diagnosticate
multiple cerebral sclerosis from the functional paralysis agitans, which
is never a very serious affection, and the seat of which is not always
centric. Besides, in the latter there are no festination, alterations of
sensibility, incoordination, muscular aniesthesia, or inability to main-
tain a continuous muscular contraction, while the paper of the dynamo-
graph traverses the pencil of the instrument. The functional disorder
is more liable to occur in persons under fifty than in those over that age.
From the cerobro-spinai form of multiple sclerosis, wliich will be fully
considered in another section of this work, it is distinguished mainly
hy the facts that the tremor makes its appearance before the paralysis,
and that the agitation is present whether voluntary movements are be-
ing made or not.

With the purely spinal form it is not likely to be confounded by
any one paying the slightest attention to the phenomena of the two
diseases.

From chorea it might in some eases not be readily discriminated
without a thorough study of the clinical history and existing 8vmptoin&
But, though chorea sometimes occurs in adults, and is generally accom-
panied by *' head-symptoms," the two affections possess few other phe-
nomena in common*

In the first place, the mental symptoms in chorea are indicative of
feobleness from the very first, while in multiple cerebral sclerosis imbe-
cility supervenes late in the course of the disorder. In chorea there are
no vertigo, pain in the head, or other evidences of congestion, while in

IfULTIFLE CEREBRAL SCLEROSIS.

285

tile disease under notice these are among the verj earliest symptoms.
In chorea there is no actual tremor, but the disorderly movements are
Bon extensive and irregular than in multiple cerebral sclerosis; neither
i» thrrc festination or bending of the body forward.

Tremor is sometimes met with aft^r cerebral haemorrhage or other
producing hemiplegia, but in such cases the clinical history, and
I tact that the trembluig comes on after the paralysis, will suffice to
iiiidftr the diagnosis sure.

Ptl^OSis, — ^The prospect of recovery is always unfavorable, but
*poif I am induced to think, absolutely hopeless if the patient be rvqu
Bciently early in the course of the disease and submitted to proper
il treatment. The probability of an arrest of the onward ten*
flencj is by no means small under like circumstances. Still, in the great
najority of cases, all means fail, and the affection gradually and per-
AStetidy goes on to its termination — death.

Morbid Anatomy. — The membranes of the brain are sometimes
ipaqa9 in patches, and occasionally contain an abnormal amount of
•eroni Haid. The cerebral convolutions are occasionally flattened, and
tke gray substance is thinner than in the normal condition. It may
abo b- 1 in color, being pale, and scarcely, according to Jaccoud,

lob^ • ;=, i^hed from the white substance.

On cutting into the tissue of the hemispheres, plates or nodules of
bttdMiad matter are found scattered throughout its extent, llie^e are
w«II Ae&aedy and vary in size from that of ii cherry-stone to that of a
mail walnut. In the only ease in which I have had the opportunity of
Oiting a post-mortem examination, they were confined entirely to the
vlilo iubstanee of the hemispheres. Their color is white or grayish-
«Ule, and they are of varying degrees of consistency, from that of
hvd-boiled white of egg to that of cartilage.

Eiainined with the microscope, they are seen to consist of the neu-
m^glk, which, to a great extent, has taken the place of the nervous tis-
nr, tad of the if^rls of this latter in the form of fibres, nucleated cells,
Mid ff^e nuclei. Tlioy are fonued, therefore, by the hypertrophy of the
«»Mictive tissue of the brain at the expense of the ner^'ous tissue proper*
Sometimes there are very few of these deposits^ndeed, there may
<*ijbe one — and at others they are present in large numbers. In the
««»» examined by myself there were seven in the left hemisphere and
tlt'ten in the right, of sizes varying as previously stated.

Th^JT may bo found in other parts of the cerebral mass besides the
*»«aiBphcre5i, though in the fonn under consideration these are their most
Froiniiu»nt and oonstant seats. Thus, they may exist in the hemispheres
*ttdin the medulla oblongata, the pons Varolii, and the cerebellum, at
the mj3\m lime. When they occupy, Ukewiae, the spinal cord, another
'^^^laie^ ill produced which differs anatomically and pathologically from
woIiir.L. oerebraJ sclerosis.

DISEASES OF THE BBAIN.

Sometimes large numbers of amyloid corpuscles are met with, but
their presence is not constant.

Pathology. — The first question to be considered under this head re-
lates to the existence of multiple cerebral sclerosis as an independent
affection — that is, without lesiofls of like character being at the same
time produced in the spinal cord.

The weight of authority is probably against the view expressed in
this chapter, and, as I have, so far as I know, made the first attempt to
identify a certain group of symptoms with multiple sclerosis limited to
the cerebral ganglia, I am the more desirous to place the reasons by
which I have been actuated before the reader.

Andral,* under the designation of partial induration of the brain,
describes the morbid anatomy of an affection which is probably the same
as that under present consideration, although his account of it is by no
means full or precise.

Valentiner,* citing a number of cases observed by himself and Fre-
richs, details one in which the lesions were limited to the brain, and in
which the symptoms were similar to those I have specified in this
chapter.

Jaccoud declares that certain cases establish the possibility of sole*
rosis limited to the encephalon. In a note he refers to several writers
who have stated the parts affected, in some of which, however, the spinal
cord was also involved. In the following it appears to have been re-
stricted to the brain:

Stoehr, hemispheres corpora mamillaria; Dumville, protuberance me-
dulla oblongata and corpora olivaria; Pool, hemispheres centrum ovale;
Cruveilhier, anterior face of the medulla oblongata, protuberance, cere-
bral peduncles, corpus callosum, walls of the lateral ventricles, and the
origins of the pneumogastric glosso-pharyngcal and hypoglossal nerves;
Duplay, hemispheres, particularly in the vicinity of the ventricles, optic
thalami, and corpora striata; Van Camp, protuberance; Obertimpfler,
hemispheres; Barthez and Rilliet, hemispheres, particularly one convo-
lution; Cohn, hemispheres in two cases; Gunsburg, hemisphere, gray
substance of the convolutions; Yalentiner-Frerichs, cerebellar pedun*
cles, corpora olivaria, protuberance, and medulla oblongata; Meynert,
cerebellum and protuberance.*

Boumeville and Guorard,* while asserting that the existence of mul-
tiple cerebral sclerosis as a separate and distinct affection rests on only
one case — that of Valentiner — which they further declare was probably

* " Precis (I'anatomie patliologique," tome ii., 2* partie, Paris, 1829, p. 810.

• " Cber die Sklerose dcs G^hims und Riickenmarks." " Deutsche Klinik," B. xiv., 185«.

• I quote this note from Jaccoud, without vouching for it8 oorrectnesa, as, from the
fact tliat he does not cite the works in which the details are to be found, I have not beeo
able to verify his statements.

* " Do la sclerose en plaques diss6min6es," Paris, 1869, p. 68.

irULTTPLE CEREBRAL SCLEROSia

|iri !%' reported, admit that the cerebral form may be regarded as

r^ . .*^..>jd. But none of the authors who have referred to it identify
4 furm of pamlysia agitans with a lesion characterised by the presence
of bodices of sclerosed tissue in the brain, and especially in the hemi-
•pberes. Thus, Dr. Clymer expresses the opinion that, exclading the
tremor, which may accompany hemiplegta and certain other disorders
«l which it is an altogether secondary phenomenon, there are but two
rieties of paralysis agitans: 1, That which results from multiple (dis-
ieminated) sclerosis, atlecting the encef)haloo and spinal cord; and, 2*
A jjurely functional disorder, iirst fully described by Parkinson.* Now,
Ui tnv opinion, Parkinson has described two very dbtinot alTectton^
ler the name of paralysis agitans. Ooe of these is certainly func-
so far as thb: that the tremor shows no disposition to extend to
dtitAiit parts of the body, that it is the only symptom present, that no
kak>Q has been discovered, and that it is readily cured. The cases de*
•cribed by him, on pages 48 and 50 of his " Essay/* were of this form,
and CWe IV^, was probably of like character. Tlie other is charac-
trrtxrd by the phenomena which I have detailed in this chapter, and
^hich, though imperfectly described by other authors, have either been
wxifoiin<ded with multiple cerebro-spinal sclerosis, or regarded as con-
fftkuttng an aggravated form of the functional disortler.

Parkitison defines it as " involuntary tremulous motion, with less-
toed muscular power, in parts not in action and even when supported;
With A prt^peusity to bend the trunk forward, and to pass from a walk-
ing lo ft running pace, the senses and intellect being uninjured."

CHrd^Dstein * is of the opinion that the true anatomical lesion of
lio»*f|ittiml tremor is yet to be found, although he refers to several
CMit in which there were organic changes in the pons Var<^>lii, medulliL
oUoo^ia, and crura cerebri. These he regards as accidental, and
thtfvfare as not being essential features of the disease. It is scarcely
unfumry to say that he does not make the distinction between mul*
tipit cerebral sclerosis and the form of tremor to which I restrict the
n^tito of paralysis agitans, and the morbid anatamy of which is still
ttn^ermtned.

My own riows of the true pathology of the cerebral form have
kefn formed from careful obser\ation of the course of the disease in
tfeei^ii easc-s, in one of which T was enabled to make a post-mortem
*ttmiiiation.

1*. B., oialc, aged sixty-five, formerly a drummer in the army, and

'*1Enft^oa iboSh I ' /' Loatlon, 1817* In Uie prt-vious etlUions of this work

Itmt fdikr^pd to ini >• obtAin a copy of I'arkitijuirs work, liad that mv oiU'

*"** (^ It nttre tbervfon? ncces^anly fioeoml-liiiiid. ObMrrlng thia italcmeai, Dr. T.
^""^^t «f ltADcbe«UT« Eiiglaciii^ n ai kind enough to preeeat me witli a copy, so ili^t I
■• *"• bllit prewcat fMiUTon to refer to Pnrkiasou directly.
"^ 1i ittrmlrnii- «gitaBtc«'* ctc., Paris, 1868, p. 20, #r Mf*

288

DISEASES OF THE BRAIN,

latterly an instructor of buglers, came under my observation at Cebfi*!
leta, New Mexico, in the winter of 1849^'50, Wbile milking a cow, one
evening, he suddenly t»xperieiieed a severe pain in his head, which lasted
only a few seconds. He soon afterwartl had an epileptic paroxysm, dur-
ing which he bit his tongue severely. He had no other fit, so far &a
was known, but the pain in the head recurred at different times, neyer^
however, lasting longer than a minute or two.

No other symptoms appeared for several weeks, and then he ex-
perienced severe darting pains in the arms, and soon afterward the left
hand began to shake. On examination I found the tremor limited en-
tirely to the extensor communis digitorum, and that the motion was
entirely in the line of extension and flexion. Little by little the other
muscles of the forearm became involved, and then the disorder extend-
ed upward, affecting the biceps, coraco-brachiahs, triceps, deltoid, and
the muscles of the slioulder generally. The arm was much weaker than
the other, although ho was left-handed,

la about three months after first noticing the tremor in the left hand,
the left foot was similarly affected, and, as in the first inatance, the
agitation gradually extended upward, until, so far as I could se^, all the
muscles of the extremity were involved.

He now complained of numbness in the ends of the fingers of the
affected extremity, and this slowly extended to the whole arm. The
sensibility of the leg remained intact*

Next the right arm went through a similar sequence of phenomena,
then the right leg, and finally the head.

There was no decided tendency to forward impulsion till both legs
were involvCTl, though there was difficulty in maintaining the erect pos-
ture, and the body was inclined forward before either inferior extremity
became affected. But with the accession of ttemor in both lower limbs,
a marked disposition to trot and a oorrespondiiig difficulty of walking
slowly made their appearance.

For over a year the tremor ceased whenever the patient went to
sleep, and it generally became less troublesome as soon && he lay down
and tried to sleep. But at last it continued night and day, and thus
apparently !iastened the temnnution of the disease, for he lost strength
rapidly from deprivation of sleep. This debility was still further in-
creased, by innutrition from proper food, it being impossible, in the
then state of the country, to get any fresh vegetables.

During the whole period from the occurrence of the first paroxysm
of pain, there was a gradual but marked failure of the mental powers,
until a contlition of very decided imbecility was reached. Death finally
took place about two years and one month after the epileptic fit, which
occurred on the same day with tlie first pain felt in the head.

1 made the post-mortem examination with great care, but without
any clearly-preconceived idea of what I should find, except that I cx»

MIJLTIPLE CEREBRAL SCLEROSIS.

2?$9

to discover lesions of some kind in the brain and spinal cord.
>%'ing' the calvariura, the membranes covering the surface of the
' koaspher

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